30519APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUHAING - ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT o PLUMss -11 BING-MECBANIe 111. CA1 L' 30 5 19
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El Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
B p rL B MP'
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 on licensed under provisions of Chapter 9 (commencing
with Sectim T000)of Division3of Ne Businesand NofessionsCMe.aadmylicenseis
in full farce anA effect
License Class Li, is
Ume Commcmr
QTY. ELECTRIC PERMIT FEE
OB DESCRIPTION
RESIDENTIAL'
DSFDWL D KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
DMULTI-UNIT ❑STRUCTURAL
MODIFICATION
ElINTERIOR D CHIMN17Y REPAIR
IMPROVEMENT
D BATH REMODEUREPAIR D DEMOLITION
D OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS UF.CLARAI'ION
l understand my plashall ta used as public records
^, / PANELS
✓ �.
UPT(y 200 AMPS
Licensed Pofcnimed
OWNER -BUILDER DECLARATION
I hatch, affirm that 1 am exempt from the Caroni License Law for the
following reason. (Section 7031.5, Bminess and Prose, ore Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
poor to its issuance, also requires the applicant for such Permit o file a signed statement
he is licensed put uan,blbupnsvl.clans.1 heCvntrucor'sLicense L.,(Chapter 9
(commencing wids Solon 7")ofDivixion 3 ofthe Business and Professions CAR)or
that he is exempt Iherefmm and the basic for the alleged exemption, Any violation of
Scene" 703I,5 by any applicant for a Nam,suhjems tha:applicumm evivil penalty of
not more than five hundred dollars (
owner off, pmpeny or myemployees with wage.wstheir sale cooperation,
willJmhe work,mdthe stmcmrc is notimendcJ otdtfcted [ar sa1,(See 904(. Business
end Professions Cole: The Contractors License taw Joos evil apply to an owner of
progeny who builds or improves thereon, :rad who Jacc such work himself or WrougM1
his own employees, provided that such improvements are not intended or offered for
sale. ILhowever,me building or improvement is .sold within one ycarofcompletion.the��'1-
e r -builder will have the bumen of moving that he did not build or improve far put-
poseof sale.). y,
D 1. as owner of the propertam exclusively contracting with licensed vmraw on to
construct the project (Sec. 9W4. Business and Professions CoJeJ The Contmelor's Li-
cera law docs not apply to an owner of progeny, who build or improves thereon, and
who contact for such pmjens with a contrastogs) licensed pursuant to the Commmmr's
law.
❑ I am exempt under See ,B& P C for this reason
2014000AMPS
OVER 11100 AMPS
SIGNS F,LBCTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL'
D NEW BLDG/ADDITION ❑ DEMOLI']ION
OTENANT ❑FOODSERVICE
IMPROVE M
DOTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES -
NEW RESIDENTIAL ELECTR SQ
�/T ���
SQ. IT. FLOOR AREA
,
H
ilk,Liana 'Q
$/SQ. FT
w
TOTAL:
QT'. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER
(/��Y
Owner Dale
VAL A
WORKER'S COMPENSATION DECLARATION
I hereby of ren under penalty of perjury one of the following deelmabon,
s� Lave and will maintain a Ccnificac of Consenuo self -insure for Workers Cooper-
I tion, asp 1idM far by Section 37W of the labor Cole, for the performance of the
work( ich this permit is issued.
ve and will mainmin Worker's Compensation Insurance, as required by Section
900 of Ne Labra Cada for the performance of the work for which this pemdt is issued.
MY Wnrkgr's Com incurg� dPulicyty1 �
Caries C- C kj& YcarlcrPmd 11-,, �Y'd
CERTIFICATE OF EXLMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ona,1e11lon neednatbeeme,feted iftheparrea isformehundmldollarsf$100)
or less.)
I verify that in the pen! inm mesal the weak far which th isperefie, ivcueJ.[shall
a employ any person in any manner so as b became subjmt to the Warren CompeeCompeer.ENERGY
n cation Laws of C.1ifomi.. Dare
Applicant
BACK MOW PROTECT DEVICE
DRAINS- FLOOR. ROOF, AREA, COND
STORIES
irth
OCC GROUP
B .DI DIVISION
TYPE CONSTRUCTIOP
nPN
FEES
FIXTURES - PER TRAP
GAS -E,. SYSTEM -I INC. J OUTLETS
GAS-EA.SYSTFJ.1-OVERJEA)
GREASIIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
pLANCHECKN.F.
SEWER -SANITARY -STORM EA.2W FT.
FE E
WATER HEATER WIVCN/ELtiCTR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Carifiama of Exemption. you should
subject nt are Workers Compensation provisions of the Ldmr Code, you mus,
forthwith comply with such provisions or this permit shall he d<emed revoked.
CONSTRUCTION LENDING AGENCY -
1hershy affirm that there is a construction lending agency for the performance of
IM work for which this permit is issued (Sec. 3097, Civ. C.)
lenders Nuc
quarkLenders
WATER SYSTEMITRExTING
SOILS FEE
WATER SERVICE
PAID
Date Raeiptk
NEW RI!SIDENTIAL PI.MB. SQ. PI'.
TOTAL:
Address
I ttrify Nm 1 have read this application and stem that the aMve mammalian is
career. 1 agree b comply wins all ary and county nrdm:mms and Ovate Ixws remang ro
building construction, and hereby authorimexprewoustivesof Nis city benmr upon the
above-mentioned property far inspection purgras.
(We) clime bars, indemnify rand keep Iwnnlexs the City of Cinema. against
liabilities,judgments,overs and expenses which ..yen any way accrue agvimisaid City
in consequence of the gaming of this permit. ��
APPLICANTUN ERS'1'ANE AND WILL COMPLY WITH ALL�jngT
SOURCERE 1'.ATION. \ I
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
1'IiRMIT' ISSUANCE
ELECTRIC FEE
gLTER OR ADD TO M[CH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10.000CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 0.000 CPM)
CORSTRUC`GONTAX
Signaw of Ap icanU Date
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or fmure building occupant store or handle hamNous material
as defined by the Cupenim Municipal Code, Chapter 9.12, and she Health and Safety
Cade, Section 25532(a)l'/
❑Yes Ih-t'p,_
Will then applicant or future building pan equipment or devices which
pp gby th ruses
omja heiardous air comaminants ac deli by the Bay Arca Air Quality Management ,Tsus:T
❑ Yes
I have moulds, hvardouc mmenak re, 25533 an under Chapterrsta of the Carie
fomia UdomHealth &Safety Gd, ee eras 255115, is my and 25534.1 understand Nm if me
building Jac. not cu early Imve a count. mat it in my responsibilitym no0fy me axcupant
,.,,he ruryhic�%Iner Orior m iscuanceo[ m Ceni(nneofOmupunty,
EXHAUST HOOD IW/UUCq
HOUSING MITIGATION FET?
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT(OVER 100,000 BTU)
PAID
Dvte Receipt a
VENTILATION FAN (SINGLE RESID)
BOILER- COMP OHP OR 100.000 BTU)
TOTAL:
BOILER -COMP (OVER 100,000BTU)
AIR CONDITIONER
ISSUANCE DATE
t1(
NEW RESIDENTIAL MECH. SO, FT.
OFFICE