30814APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/FERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO. JK ^081
VX
4
BUILDINGADDRESS:
0880 a
SANITARY NO.
APPLICATION SUBMITTAL PATI
R'S NAME PHONE : y
NE:l 09-7- �`^ / -cot - 4 • ✓71r
CONTRACTOR'S NAMIi: r LIC NO,
'V(5 iQ o { em (6216
NIC
❑
CONTROL«
\RCHITECf/ENGINEER: LIC NO:
Aj)DRES,S:C vepujw
lIQgJJ 225`V'e
CONTACT. PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECTPLUMB MF,CH
❑ ;? ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
of Chapter 9 ¢mmnenang
I hereby )ofEthat 1 am licenced tinder nd Professions
ion3 rime Business end Rofcssions Gude, and my license is
with Section and effect.
in fall c Class de(fat.
License Class Conn
I Dae
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL -
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT' ❑STRUCTURAL
MODIFICATION
Cl INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR El DEMOLITION
[]OTHER
\ PERMIT ISSUANCE
1
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
TS DECLARATION j
1 understand my plans shall be used as public records
PANELS
UPT02q)AMPS
LiccnmJ Professional
I m Ce Cona ON
Oat I am exempt from
C I hereby affirm that 1 em eumpt from the Contracmr.c License Law for following rcawn. (Section 7031.5, Business and Professions Cale: Any city or count,
jc which maims a permit m c nm naL alcor, improve, demolish, or mpair any awaum
1 prior to its issuance, alsomqulres the applicant forsuah pennittu IIIc u. signed statement
that he is licensed pursuant to the previsions of me Commuters License law (Chapter 9
(commencing with Section]000) of Division 3 of the Business and Professions Cads)or
that he is exempt therefrom and the basis for me alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollar, Sim).
❑ I. as owner of the propcny, of my employees with wages as their sole compensation,
will do Be work, and the structure is not intended or offered hostile (Sce. 104q Business
3 and Professions Cede: The Contractor's License law does not apply to an owner of
• property who builds or impmves thereon, and whit does such work himself or through
his own employecq provided that such Improvements me not intended or offered for
one. ll; hottest, the building or improvement issold within one yea of<umpletion. the
caner -builds will have me burden of proving that he did not build or improve for For -
,we of sale).
1, as owner of she property, am exclusively contracting with licensed contractors tit
constlmet the project (Sec. 1(W, Business and Professions Codc;J Ttrahe Con1-r Li-
cerce law des not apply it) an owner ofpropeny who builds or improves thereon, and
who contacts for such projects with a commcmrfs) licensed pursuant m the Contractor's
License ext
❑ 1 am exempt under Sec. , B & P C for this rtaon
201-1(XOAMPS -
OVER 1(1(NIAMPS
SIGNS ELECTRICAL
SPECIAL CIRCULUMISC.
TEMP. METER OR POLE INST.
COMMERCIAL
❑NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDEMI'IAL ELECTR 'SQ EL
SQ. FL MOOR AREA
p ' D
�1
AA?
�o ��
1.
ESQ, ET.
- T
QTY. PLUMBING PERMIT EE
PERMIT ISSUANCE
ALTER -DRAIN k VENT- WATER (EA
BACK FLOW PROTECT DEVICE,
Data
�Owner WORKER'S COMPENSATION DECLARATION
n I hereby affirm under penalty ofperjury one ofthe following dcclumtionc
(] I have and willaromme.it Certifieme of Consent to self -insure for Workers Co.,.-
ratas ion, provided for by Section 3100 of the Labor Cade, for the performance of the
work for which this Permit in issued. '
E] 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M ofthe Labor Coal,for the performance ofthe work for which mi.s permit is issued.
My Win 's Com eusdtion Insurance carrier and Policy nynyp{Lar �4
Canicc {`Policy No.:—
CERTIFIC TE OF EXEMPHON PROM WORKERS'
COMPENSATION INSURANCE
pa��
fRtissection need not he completed it he t is for one hundrod dollars 10i)
or Ices.)
(certify that in the performance - ofthe work for which this permit is issued, lshall
not employ em nary mm .•. n� re subjcenn the Wor kers' Compen'
cation f (Cab u ire. Dae -
Applic m
`l•-�•NC�/1/D ON
DRAINS- FLOOR, ROOF AREA. COND.
STORIES
E
TVPCONSTRUCTION
FIXTURES -PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
(JCC. GROUP
pPN
GAS-CA. SYSTEM -OVER 4(EA)
GRE ASEIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
BUILDING DIVISION PEES
PLANCHECK MI,
gEWIiR- SANITARY -STORM EA. 2UII14.
ENERGY PEE
WATER HEATER WATNT/ELECTR
GRADING FEE
N09'IC i TO AI' ,(CANT: f, a p-t(tis Cenificu of Exemption, you should
became . o me Workei x Com nsatinn provisions of me Ubor Csdc, you mu.n
forthwith complywith.vuch provisions or this permit shall hcdecmeJ revoked.
CONSTRUCTION LENDING AGENCY
I hercM1y uffrm aha there is acnnumction lenJing agency for the performance of
the work for which this permit iso wed (Sec. 3091. Civ. C.)
Under', Name
WATER SYSTEM/IREATING
SOILS FEE
WATER SERVICE
PAID
Date Receiptg
NEW RESIDENTIAL. PLMB. SQ. Fr
TOTAL:
Tender's Address
1 cenify that I have read this application it nae that me above information is
tea.1 agree an comply win -Il city and county ordinancesand,tatelawsadenogto
building conswaion. end hereby aumodzc mprtsentntivex of this city m enar apm me
above-mentioned property for inspection purposes.
(we) give m save, indemnify and keep harmless the Coyof Cupsnine, against
costs and expenses which may in any way accme against said City
of the granting of this permi,
ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
3 q,
TOTAL
BUILDINE
QTY. MECHANICAL PERMIT FEE
SEISMIC
PERMIT ISSUANCE
ELECTRIliabilities,Judgmems,
ALTER OR ADD TO MECH,nseyacncc
PLUMBINeco
AIR HANDLING UNIT CIO 10,000 CFM)OURCE,REG
MECHANEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
"gnaw fA,lacriffallifITTI717ir Dam
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building ueoupeni itom or handle animations material
as defirad by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code. Section 25532(,)?
O Yes'
ma WiII me applicant mfurore defined occupant use equipment or devices which
ma, hazardous aircomaminantx as defined by me Hay Arca Air Quality Management
DistricR `'
El Yes DWo
I have real me hazarddoo--usmaterials requirements under Chapter 695 of be Cali-
- Su[et Gxle, Satiom 255(15, 2553) and 25534. 1 understood thus if the
building dies note teem, that it is my mspomsibilitymnutifythe acupant
of the mquiren hich man met prinnuixsuanccofa Ccrtimc�ecupunq.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.0(() BTU)
HEATING UNIT (OVER IM.(1(0 BTU)
PAID
Dae Receipt M ,
VENTILATION FgN(SINGLE RES ID))
UOILER-COMP (3HP OR 100,000 BTU)
TOTAL'
BOILER - COMP (OVER 100,000U'IV)
AIR CONDITIONER
ISSUANCE
ISSUED BY _�
NEW RPSIDENTIAL MECH. SQ. FT.
orired ag Uvtt
TOTAL:
_.
OFFICE'