29476 (2)2PLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ITY OF CUPERTINO BUILDING - RL.ECTR
BUILDING DIVISION APPLICATION/PERMIT PLUMPING —MECIIAI
(Qq?S Pr2-t
OWNERS NAMI
LL
;III'I'EGTIENCINEEH:
CONTACT CONTACT.
' ` CT .
OC 1 hereby aRrm Out 1 am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 oOhc Business and Professions Cade, and my license is
�� inena orce and effec cl Z& 61
kcUU License Class hie.# Ll0 70
rF�va Data Contractor
ZO=p ARCf11T1iCT5 DECLARATION
1 understand my plans shall be used as public records
0
F+R? ail Licensed Professional
In co,
❑ Consultant Fees Paid by Applicant (Initial)
ITY. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMPS
OWNER BUILDER DECLARATION
ti 04 41 Q I hereby affirm that 1 am exempt Tram the Contractors License Law for one
x 3 6 V following reason. (Section 7031,5, Business and Professions Cale: Any city or county
F .�. C which requires a permit to comuuct, alter, improve. mo
pve. delish, inrepair any structure
y prior to its issuance, also requires the applicant for such permit to rile a signed statement
Oaf that he is licensed Pursuant o the provisions ofthe Contractor's License Law (Chapter 9
0 0 (commencing with Section Mirror Division 3 ofine B uric s and Profession., Cale) or
d y y tum he is exempt therefrom and the basis for Ne alleged exeption. mAny v4dwima of
YX7 Yy Section 7031.5 by any applicant for a permit subjects the vpplicam m a civil penalty of
�Cnee marc Nan five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, Rod the structure is not intended or offered for We (See. 7044. Business
G3 and Professions Code: The Contractors License Law does nor apply to an owner of
properly who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
Rule. If. however, the building or improvement is sold within one yam ofcompIa ion, the
nwnerh adder will have the bathe. of moving that he did not build or improve for pur-
Fi a mrame.).
C I, usenm r of the property, excluxivoly contracting wish IicenecA cmm�v:urte to
consumer theprnject (Seo. 7(94, Business and Poinssions Coda:) Tho Comrueuds Li-
ReLow does not apply room owner ofloopeny, who builds or improves rherenn,and QTY,
who contracts for such pmjects with a contmmons) licensed pursuant to the Comparin's
License Law.
❑ Iatnexemprunder. Sec. ,B&PCforthisreasun
Owner Dare
WORKER'S COMPENSATION DECGRATION
1 hereby affirm under penalty of perjury one of the following dedamtlona:
I have and will maintain a Cenific to of Consent to self -insure for Worker's Cnmpcn-
satinn, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued,
❑ I have and will maintain Worker's Compensation Inmmnce, as required by Section
37N) of the Labor Code, for the performance of the work for which this pemtit is issued.
My Worker's Compematian Insurance carrier and Policy number am:
Carrier. Policy Nm:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Rection Occur, be, completed ifthe pcnnir is feature hundred ddlam PiRXB
or less.)
I candy that in Ne perfn ance ofthe work for which this permit is issued, I shall
nm employ tiny n v y n to bj come uM111'e9 ro the Workers' Compnn-
O z amino Lawn q(b(9�nm, n n r] L
O Applinmt—Lad/ cr, �Qk.o I
N NOTICE TO1 CANT. IL after making this Certificmc nl I: entprinn, ymr should
h hecame subject miss, Worker's Compensation Provisions of the Labor Cale, you most
Qfanhwidt comply with such provio nu ear this permit shall N deemed invoked.
7 z CONSTRUCTION LENDING AGENCY
U O l hereby aBimt that there is v commuction lending agency for the performance of
P: the work for which this pen tit is issued (Sec. 3097, Civ. C.)
O U Lenders Name
W Lender's Address
y I certify that I have read this application and state tom the chose inl'ormatinto is
Vl cnrract.l agrco to comply with all city and county ordinances and stare lows relating to QTY..
U y building construction end hereby authorize representatives ofthis city roomer upon the
above mentioned property for impecrion pmpmms.
(We) agree m save, indemnify and keep handless Or City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue ugainn mid City
I. consequence of thegranIin�gyy''f this permit.
APPLICANT UNDERSTM, AND WILL COMPLY WITH ALL NON POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mmdclpul Code, Chapter 9,12, and the Health and Snfety
Cute, Section 25532(x)7
Dyes I-) No
Will the applicant or future building occupant use equipment or devices which
emit hazmdous air contaminants M defined by the Bay Area Air Quality Management
Disoict7
❑Yes EJ No
1 have read the haza dmis materials requirements under Chapter 6,95 of the Cali-
fornia Health & Safety Code, Sections 25505, 25533 and 25534, 1 understand That if the
building does not currently have a tenant, tout itis. my responsibility to notify the occupant
of the requirements which must be mer prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date
OVER RMAMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. ME TI?R OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEC R
PLUMBING PERM IT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (G)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, CORD.
FIXTURES - PER TRAP
GAS -G. SYSTEM -1 INC.4 OUTLFTS
GAS -PA. SYSTEM -OVER 4(HA)
GReAmINDUSTRL WASTE RgTERCHPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WR'I'ER IIIA- 1'ER wA T/ELEC'1'R
WATER SYSTEMI7RGTING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. f ..
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTLRR OR ADD TO MECH.
AIR HANDLING UNIT (TO I0,000 CPM)
AIR HANDLING UNIT (OVER 10,001 CPM)
EXHAUST I IOOD(W/DUCH
HEATING UNIT 170 100,000 BTU)
HEATING UNIT (OVER HMNM BTU)
VEN TLXI'ION PAN (SINGLE RRSID)
BOILER-COMP,GHP OR 1011,008 BTU)
HOILER- COM P(OVER 100,000 BTU)
AIR CONDITIONER
N FW RESIDENT IAL MECH. SQ. FT.
OFFICE
0�AL,
C KITCHEN REMODEI.
29476
CPLUMBING RE -PIPE
C MULTI -UNIT
SANITARY
NO.
APPLICATION SUBMITTAL DATE
'-A Z O
❑INTERIOR
❑CHIMNEY REPAIR
N/C
CONTROL#
C OTHER
I
COMMRRGIAL:
C NEW BLDG/ADDITION
BUILDING PERMIT INFO
❑TENANT
BLDG
ID
ELECT PLUMB MECH
❑
FEE
0�AL,
C KITCHEN REMODEI.
❑ADDITION
CPLUMBING RE -PIPE
C MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEL/REPAIR D DEMOLITION
C OTHER
I
COMMRRGIAL:
C NEW BLDG/ADDITION
❑DEMOLITION
❑TENANT
❑1'001) SERVICE
IMPROVEMENT
❑OTHER
SQ. FT. FLOOR ARG LSQ. PT.
FEE
PNp
MAR 19
VALUATION
Y UI• UurCrr I try(/
BUILDING DIVISION FEES
PGNCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
TOTAL:
BUILDING FEE
FEE SEISMIC
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCDONT X
HOUSING MITIG ION PER
PAID
Date Rcceiprp
TOTAL
ISSUANCE DATE