S 1113 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C BUILDING ELECTRICAL FIRM IT No
CIT,1 OF CUPERTINO S 1113
I BUILDING DIVISION APPLICATIONIPERMIT PLUMB
ING PROJECT
ECIIANIFIC
BUILDING PNOJHCT IDhNI'IFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
W ili'S NA E: PHONE: CONTRACTOR'S NAME: LIC NO:
i �s NIC CONTROL p
\RCIII'I'f?Cf/.NGINEER: LIC NO: ADDRESS', ❑
CONTACT: PHONE: BUILDING PERMl'1'TINE
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
DMZ with Section 700lof Division 3 ofthe Buvimessand Professions Cadc,and mylicense is RRESIDENTIALIW-1_ full force and effect. PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL.
�UV
in
Class Lic.g APPLIANCES—RESIDENT AT, []ADDITION ❑PLOMUNIT RE-PIPE
F.Zu) [)allCom moa or
NQ iL ❑MULTI-UNIT ❑STRUCTURAL
F.7 n ARCHITECTS DECLARATION PANELS
I understand my plans shall be used as public records MODIFICATION
oZ a UETO200AMPS
El INTERIOR [1CIIIMNF.Y REPAIR
[, U,enwd Pmficadonvl 201.1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDHR DECLARATIONpyER I(NN)AMI'S
M ❑BATH REMODELIREPAIR C1 DEMOLITION
1 hereby afftm lam N
that I am exempt Ie Contractor's License Law far the
U lallnwing mason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHEk
F' which acquires a permit to consumer,alar,improve,demolish,or repair any swctureOP
O prior to its issuance.also requires she applicant for such Permit o file a signed statementSPECIAL CIRCUIT/MISC.
that he is licensed pumer,to the provisions of One Contracm/s License Low(Chapter 9 :AzAtlz a !T Otto
�COp (commencing with Section 7000)dDivision 3 ofthe Business ental Professions Cock)or TEMP.MMR ON POLE INST. COMMERCIAL:
6y oq that he is attempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
x^N Section 7031.5 byanyapplant fora Permit subjects theappheanuoa civil Pcn.Ity.f POWER DEVICES []TENANT ❑FOOD SERVICE
W Z y no more Phan five hundred dollars(5510). IMPROVEMENT
Q ❑ Las owner ofthe property,Or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
wall do the work,and the someone is not intended or offered forsale(Sec.70,14,Business []OTHEROTHERsomeone
W and Professions Coda The Co trunims License Law does not apply to an owner of OUTLETS—SWITCHILS—I'IXTIIRES
�' .. property who builds or improves demon.not who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT.
sale.IL hmwevea the building o impmvement is sold within are yamorcompletion,the SQ.FI'.FLOOR AkIiA $ISQFT.
.
owner-builder will have the human of proving that he did not build m impmve for Pur-
,,mnlstant convenors
ale.). P-411)�I
❑ 1,as owner of the property, exclusively contracting wish licensed m TOTAL: gyl 1 q
instruct the project(Sec.7014,Business and Professions Cale 3 int Commcusr s I— Y
cense Low does nm apply to enowpar of penal who bullas or improves dorrum,and QTY, PLUMBIN ERMIT FEF. ff{/.�
who contracts for such projects with a contmnnr /Q(s)licensed pursuant to the Contractor's V f
Lica se Law. PERMIT ISSUANCE ANS }
l am exempt under Sec. ,B&PC far this reawn
' ALTER—DRAIN&VENT—WATER(EA) (yp.VALUAFION
Owner Date �nf V
WOR ER'S C MPHNS '1'10 F.CLARATION HACK FLOW PROTECT.[)it li
I hereby alfirm under penalty of pc Ju c afire fallowing declarations.
❑ Ihme ondwill maimaina Ceni0cete of Cansenuo self-Insurefor Warkor's CnnnPcm GRAINS—FLOOR,R(IOF,AREA,GOND' TIENERGY
RIES 'PYI'E CONSTRUCTION
moon,us pnwiJN for by Section J7(Nl of the LaMrt Cafe,for the pertarmance of the
work for which Nis permit is issued.
FIXTURES—PER THAI'
I have and will maintain Worker,Compensation Insurance,h required by Section
l]Wnf the Labor Code,far the peRn.....f Ne work for which this permit is issued GAS—EA.SYSTF.M.I INC.40UTL8'1'SROUP APN
My Walker,Compensation Insurance carrier and Policy number art:
Comer. Policy Nu: GAS—EA.SYSTEM-OVER 4(EAI
CERTIFICATE-OF EXEMPTION FROM WORKERS' GkIL45FlINDUS'1'RL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need not he completed if the permit is for one hundred dollars($1101 GRGASETRAP
or less.) EE
I marry that in the performance Ofthu work for which this Permit is issued,l shall SEWER—SANITARY—SrI ORM EA,210 FE
not employ an,pro mn in any amnner so as ti)become subjecta the Worker,'Cumpsm,zsulion laws of California.Date WATER HEAL'fill W/VHN'I FTECI'kEE
Applicanl l
a Vl NOTICE TO APPLICANT.if,at,,making this Cenifertmof E.chroon,you should WATER SYSTEMO RHA'I'INC,
I" become subject mo the WarCompensation provisions of the Labor Conde,you mum SOILS FEE
Emhwith comply with such provisions O,,his permit shall be,deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESNENTIAI.1'LMB. SQ.FT. PAID
V O l hereby affirm that there is a construction lending agency for the performance of Doe Receiptp
OP: the walk for which this Permit is issued(Sec.301 Civ.C.) TOTAL
V Landees Name
TOTAL:
Lender's Address
I cenify that I have read this application and state thin the above infonnminn is BUILDING PEE
it0 correct Iagree to comply with all city androomy ordinances and state lawsrelatingto QTY. MECHANICAL PERMIT A
SEISMIC FEE
V building construction,and hereby authorize representatives of this city Ili enter upm the L %—_w
uhavc-naminned property for iiepern ipurpose,. PERMIT ISSUANCE -
(We)agree to save,indemnify and keep harmless the City of CuPcnam against IiLIiCTRIC FEE
Iiuhilities,judgments,costs andexpenses which may in any way accrucagaind said City ALTER OR ADD TO MECIL PLUMBING FEE
in consequence ofthe granting of Nis permit.
APPLICANT UNDE NDS AND L COMPLY WITH ALL NON POINT All HANDLING UNIT('1111,1111 CPM) MECHANICAL FEE
SOURCE GUI NS.
AIR HANDLING UNIT(OVER I0,000 CFMI CONSTRUCTION TAX
Sig a 'aanU ommnar Doe EXHAUST HOOD(W/DUCD HOUSING MITIGATION ME
HAZARDOUS MATERIAL. LSC SURE
Will theapplicantor futurebuildingtacupant store orhandle hazardous material HEATING UNIT(TO RNkINO BTU)
us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532ho? HP.ATING UNIT(OVER I(NI,(NN)UT U)
Dyes F1 No VEN'I'lLAT10N PANS I ROLE RESID) PAIN
Dote kecuipt p
Will the applicant or future building truculent use equipment or devices which ROLLER—COMP(341P OR 100,000 RTU)
'coil hazardous air contaminants as defined by the Bay Area Air Quality Management IfylAl,;
Dkthet? BOILER—COMP(OVERE ,qNI BTU)
❑Yes 0N
I have read the hazardous materials rryuiaments under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code.Sections 25505,25533 oral 255.14.I understand that if the NEW RESIDENTIAL MECIL SQ.FT.
of the ac Noes nm currently have a antral that a is ua responsibility to edify the Occupant v V
of the req does
hot c which must be met prior m issuance actor a Cenlficatn of y the pi occupant
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE
f