S 1056 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BUILDING.FLECT'RICAL ONO. 1056
BUILDING DIVISION APPLICATION/PERMIT PLUMRING.MUCBAN'1CAL
'BUILDING PR(IJEC.T IDENI II ICA'1'I0N
BUILDING ADDRESS:
ffiSANITARYO AI'1'hICATION SUBMITTALDATE
u 621OWNERSNAMP PHONE: CONfRAC'IO :SNAMI?: IJC NO:r _ tCON'1'k01.#ARCHITECT/F.NGINEER: LIC NO:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DE 'RIPTION
1 hereby aff rat that 1 um licensed under provisions of Chapter 9(commencing
GCO with Section7")of Division 3 of the Business and Prodasions Cade,undmylicemeix RESIDENTIAL:
Won PERMIT ISSUANCIi
F�
in fall ❑SPDWL ❑KI' NREMODEL
�U�~,l Licens Cies Lia# AI'PLIANCI!S-RfSIDENTIAI. ❑ADDITION El PLUMBING RE-PIPE
Fstl Date
oy pARCHITCGSDECLARATION
ARATION ❑MULTI-UNIT ❑STRUCTURAL
F-D y Ai
ATION
z p?2,Z� lunderrand my plans shall he used as Public records CHIMNEY
OyJJ IJP T0Ig1AMl'S ❑INTERIOR ❑CHIMNEY REPAIR
I- Licensed Professional 201-1050AMPS IMPROVEMENT 0SWIMMING POOLS
z�S OWNER-BUILDER DECLARATIONOVERIIIN0AMI'g ❑RATHREMODEIIRFPAIR OLITION
yy C 6 I hereby aff tm that I am exempt from the Contractor's License Law for the
CrW6following reasom(Section 7031.S.Busine#a it Pmfemiom Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 V-I` which requires a parotin m nmswct alma improve,demolish,or repair any stmnurc
1=.0 prior to its issuance,also requires the applicant for such permit to file u signed statement It SPECIAL CIRCUIT/M ISC.
.!{} that he is licensed pursuant to the provisions of the Contractors License Low(Chapter 9
apo (commencing with Section 70,10)o11Division 3 ofthe Business and Professions Code)orTEMP.MIG'ER OR IY)LL'INST. COMMERCIAL:
a q C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
ib. Try Section 703 L5 by any applicant for a Permit subjects the applicant to a civil penalty of FEWER DEVICES []TENANT ❑FOOD SERVICE
b.
not more Nan five hundred dollars(SSW). IMPROVEMr
=0 01,as owner of the property,or my employees with wages as their sole compensation, SWIMMING PO0L ELECTRIC
F. ill do the work,and the strucmm is not intended or offered for side(Sec.7Du,Business ❑OTHER
w
Is�j m and Professions Cale:The Contractors Littera Law docs not apply to an owner of OUT LVrS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employes,Provided Nat such improm
veents am not intended or offered for NEW RESIDENTIAL ELECTµ SQ 14.
role.If,however,the building or improvement is sold within one year.fcnmpletion,the SQ.IT.FLOOR AREA EISA.Ff.
awnecboilde,will have the burden of proving thm he did not build or improve far pull
pose of sale.L
❑I,as owner of the pmpeny,am exclusively contmeting with licensed contractors to TOTAL. p
onxtruct the project(Sec.]DLL Business and Peafic sinus Code:)The Contractors Li-
scam law does not apply to on owner of property who holds or improves theram.and Q'py. PLUMBING PERMIT IFF, ®A
whocomrectsforsuchpmjrall with laminations)lirenced pursuant lathe Cuntmemrs MM gs�
Li nu law. 1'1iRMIT ISSUANCE
�� /sem
exempt under Sec. .B&P C for this reason {a Vis#.
ALT
NOwne WORKER SCOMPENSATIONIlECLARATION BACIKFIOWPROTECEDEVICEH(1iA) ��tH)lNO
I herehy affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Coal DRAINS-FLOOR.HOOF,AREA.CONI). ST'ORIFS TYPE CONSTRUCTION
sari ss provided(or by Section AM of the InMrc Code,for the performance u(the
work for which this permit is issued. IBXTURES-PER TRAP B
1 have and will maintain Workers Compensation Imumnce.a required by Station
3700 afthe Labor Cale,for the performirwauf the work for which this permit is limed. GAS-RA.SYSTEM-I INC.4 OUTLET'S DEC.GROUP APN
My Workers Compensation Insurance carder and Policy number me:
Card, Policy Nn: GAS-EA.SYSTUM-OVER 4(EA) Qtf�,�a ��
CERTIFICATE.OF EXEMPTION FROM WORKERS' GRPASIUINDUST'RI,WAti I'IiINI'f:RCf:PPOk I�bY
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This section need out he completed iHhe permit is for one hundred dollars(S I(KE GREASETRAI' ♦�
or less) YL E I� t NO
I certify that in Ne performance of the work fur which Nis permit is issued,lshall SF.WCR-SANITARY-ST ORM EA.201 Ff.
not employ any nn in any manner sn as I been u_b art to the Workers'Cooper.
ENERGY IA!G
Qz mtinn Lawso tell m m WATER GRATER WNBNI'/1!LECIR GRADING FEE
Z Applicant 17
is
v.# 4 NOTICE TO P AI L aper making Nis Carfaare of Escmption,you shoulJ WA'1'EH$YS'H?M?kliA'1'ING
a7 become subj .t o the Warkers Compensation provisions of the Labor Calc,you moat SOILS FEE
ISI fonhwon comply with such provisions or this Permit shall be domed revoked. WATER SERVICE
UO ff them
C0NS0st LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ III. PAID Date Receipt#
1 hereby arat that ert is is aa construction lending agency for the Performance of
the work for which this Permit is issued(Sec.3097,Civ.CJ
F' TOTAL'
Lenders Name
LUE1 Lenders Address '1 OTAL:
y I certify that I have read this application and state that the above information is BUILDING FEE
In correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
G buildingcommuction.andhtualn, uthtrioamlresentmivcs ofthiscitym etnerupor the SEISMIC IF,
above mentioned property for inspection purposes PERMIT ISSUANCE(We)agree to save,indemnify and keep harmless the City at Cupadro against ELECTRIC FF.H
Iiabilitiesjudgments.costs and especial which may in ally way acemeagainst said City pCl'ER OR ADD 70 MECfl. PLUMBING IEEE
in consequence of the granting of this Kong.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10,11X1 CFM) MECHANICAL FEE
SOU EGULA S.
Lb_-2 -Q7 AIR HANDLING ON['I'(OVER UIJXNICFM) CONSTRUCTION TAX
St)*dAPPliamr/Contractor Dutn HXHAUS'f It()()[) W/DUCT) HOUSING MI'I'IGATION PEI!
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hunrolous material H HATING UNIT TO iormig1 in Lit
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health one Safety
Cade,Section 25532(x)? HHAI'INC.UNIT(OVER 10Nllgap R'flll
❑Yes ON. V ENTILAI[ON FA N(S I NGI.17 RI?SIIA PAID
Date Receipt#
Will the applicant or future building occupant use equipment or device,which ROILRR (3HP OR IINI,IIIX)BT'U)
emit hamMous air comomlnonts as defined by the Bay Arca Air Quality Management TOTAL
lDistrict?
t ❑Yes ON. BOILER-COMP(OVER 10,0111IITID
I have read the brmmlous materials requitemenm ander Chapter 6.95 of the Coli- A I R CON Of 1'ION 1!R ISSUANCE DATE
forms Health&Solely Code,Sed.ses 25505,25533 mad 25534.1 undersumd that if the N17W RESIDI?N'I'IAL MECH. SQ.IU'.
build i ancvrrenlly have o tenant,that it is my restmosihilay to notify the occupant
all requir tenni hmust Fa mm rnr to iosuancc nlnCenilicom nfOtanpnncy.
O nrizcd ogcm IDwn TO'T'AL: ISSUEDIM
OFFICE