S 0357 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOB.)IN(;-ELEcrRICAL rEµ^H'r ND
BUILDING DIVISION APPLICATIONIPE RMIT 1`ING P OJEGNG RCl1ANICC \. 0357
BUILDING PROJF.LT IUF.NTIFICATION \\l!!!
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMI'1TAI.GATT
wNER'S NAME: ^PHONE: CONTRACTOR'S NAME: LIC NO:
i 73 i
NIC CON GIOI.#
Call /ENGINEER LIC NO: ADDRESS: ❑ (/���
CONTACT: L PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ILDG F.LIS I MF.CH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRI TION
Da'Z with Section 7000)af Division lofine In,mcxx and Profesniom CMaand my license is RESIDENTIAL:
W O p PERMIT ISSUANCE
FALL= in full since and c0'cn. ❑SPDWI, ❑KITCHEN REMODEL
QUJ Licens Class 1.iaN IAPPLIANCES-RESIDENTIAL []ADDITION ❑I'hUMIi1NG RE-PIPE
y�SW ])ate Contract
ARCHITECTS DECLARATION []MULTI-UNIT El STRUCTURAL
ZO�Z_ ]order smnd my dion,hall be used as public record PANELS MOUE IICATION
OZ� UP I'02W AMPS ❑INTERIOR MO
Licensed Professional 201-1(0)AMPS - IMI'ROVFMI!NT &IiII714MING POOLS
OWNER-BUILDER DECLARATION OVERI'MX)AMI'S El ODEL,REPAIN ❑DE,MOLITION
I hereby xlfiam thin 1 am eacmp from the Contractor's License Law for IM1c
x 3 d U following reason.(Section 70]1.5.Business and 1 notion,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL vFi which requires a permit to construct•alter,improve,demolish,or repair any structure
•Fs��6 priono its issuance,also requires the applicant forsuch permiun life o signedstatement SPECIAL CIRCUI'VMISC.
thin he is licensed pursuant o the provixionsofthe Conmim's License Law(Chaphert)
u�1aC� (anamervingwith Station of Division 3 ofaha Business and Pn fe,van,Codclof TE.MII MET ER OR POI.Ii INS'r. 1 1'
dao= that he Is exempt therefrom and the basis for the alleged exemption.Any violation of 'iW B DGIADDITION ❑DEMOLITION
^
XLL Section 70315 by any applicant a permit subjects mcapplicant ten civil penaltyof POWER DEVICES
an ❑ . NT ❑FOODSERVICE
not marc than rise hundred dollars(85(X0.
FZY IMPR VF.MENT
=6 0Lasowner ofthe property,ormyemntended with wages astheir nx.compenmfeli, SWIMMING POOL,ELECTRIC 1.
andwill domelions node:he Comis roluchn's Licensed e
do furor apply 7644.Business ❑0'rHER
0.3 m and erly wh nm Code:The Gnnmauh Llcenxc law does not apply is an manor of OVI'LFTS-SWITCHIiS-FIXTUH
properly who builds or provided
es thereon,and who docs such work himself or through
his own oveser.the prodded that such mens is sold am not intended or offcted for NEW RESIDENTIAL ELECTR SQ PC
owner-e. :,ower will h ve building of proving
it at he did non Wild
or
prove for the �G. Pr.Iq,O ql , gISQ.I'I'.
puowner-Hodder will have the burden or proving mat he aid not bate or improve rna Our- !o Z
c of ov,ne
❑1,as owmr of the property,am exclusively contracting with license]contractors to TWg
contract the project(Sec.7014,Business and Professions CMa:)The Contmctors Li_
scow Law dans not apply to an owner of property who builds of improves thereon,and QTY. PL PE T EE
who caramels Tor staph projects with a contractors)licensed puma.,,,the Contractors h LGr`
Littnw Law. PERMIT ISSUANCE �T/N
❑I am exempt under Sec. .It E Is V modiste....n
AI:TI!H-UHAINk VEIEA) spa' VALUATION
WORKER'S COMPIiNSA'TIDN DECLARATIONBACK FLOW PR(YTF.C'1'.DIiVI E j
1 hereby affirm under Penalty of perjury one of the following declaration,
❑Ibas'e and will maintaina Cenifar¢ofConseni mself-insure fin Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCIIOp
nation,as provided for by Section 3100 of the labor Code,for the performance of the
weak for which his permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
3700of the labor Code,for the peffrrmanceof IM1c work far which.his permit is max,1 GAS-EA.SYSTEM-I INC,4OUTLETS OCC GROUP APN
My Worker's Compcnmtion Insurance carrier and Policy rmnber arc:
1 Cmricr: Policy No.: GAS-EA.SYS-FEM-OVER 4 d1G
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREsSERNDUSTRI.WASTE INTERCEPTOR
BUILD VISIUN FEES
This vection need not bemmpinal it the permit is for one hundmldo]lnrx 181(X11 GREASETRAP ar less.l PLANCI{ECK
! Icenif bra in the performuncenfmc work for which this permit in mo,vil.[,hall
SEWER-SANITARY-STORM EA.20X1 IT.
nm employ any person In any manner so es to become subjecuo the Wor4ri Compen- ENERGY 'S
�z .lion Lawsof C.1domio.Dat, WATER HEATER W/VENT/IUPCTR
z 2 Applican GRADE
FN-a NOTICE TO APPLICANT.II,after making this Certificate of Exemption,you should WATER SYSTEMR-BEATING
a , hraome nuhjen m the Worker's Compensation pnwoimo of the Lulus Code,you must SOILS
W
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Uz CONSTRUCTION LENDING AGENCY NEWRESIDENTIAL YLMB. SQ.FT PAID
V 0 k for
which
rte mauhere isaam(See.T len die.agency trn We perGrnnunm of Dina RecciplN
the ami for which this permit is issued(Sec.lri9],Civ.Cd
Q Landers Name TOTAL:
V tender's Address '1 TOTAL:
Hy 1 eerily that I have read this ap,lienor and mate mat the above information i, BUILDING
Z) correct.1 agree aocmnply with all city and county ordinances and,mm laws reWfng m QTY_ MECHANICAL PERMIT FEE
U building comtmction.and hereby amhorve representatives of this city to enterupon the 5131SMIC FTI
above mentioned pmpcoy for inspeeainr purpo,m' PERMIT ISSUANCE
(We)ago.to save,indemnify and keep harmless the City of Cupeninr against ELECTRIC 1 :E
Ifabiblie,,julgmenp,cns1,mdes,lnevwhiah may in any wayaccmeagam,lmid Cgry ALTERORADDTOMECL
in ,sequence of the granting of this permit. PLUMBING
APPLICANT UNDERS NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000CFM)
SOURCE MECHANICAL FEF;
AIR HANDLING UNIT(OVER 10.000CPM) CONSIAUCTIONTAX
Signaturerf ApplicaMCommctor am EXHAUST HOOD(W/DUCry HOUSING MITIGATION FE.
I{AZARDOUS MATERIALS DISCLOSURE
Will Bart,liettmorfmurebuildingeocuponl.mmmorhandle harnNousmmenal HEATING UNIT(TO 1(X1.0010 BTU)
as deli red by IM1c Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER 100.00)BTU))
❑Yin ❑No
VENT]LATION FAN(SINGLE RES ID) PAID Dom Rcmipak
Will the apps icam or future building occupant use equipment or devices which
mit haaafdous air comanimants as defined by me Buy Arca Air Quality Management BOILER-COMP(3HP OR 100.100H'TUI
O"hic,n TOTN.:
❑Yes [3 No BOILER-COME(OVER 101.000 B'IU)
I have read the havufdon,materials redivairm,under Chapter b 95 of ane Cull- AIR CONDITIONER
I ISSUANCE DA'I'S
(omitHealth mSafety CMe.SreRansi .dida255JJand 25511.I Understand that ifthe NEW RESIDENTIAL MECH. SQ.FT.
buildingdxsnn.ts which have a,mute,ior o ismyceofaCenaymanotify mupancyun.
of the requirements which must be met gi0n0 issuance of a Crnil3ca¢M Occupancy
Owner.,maharioad agent Date 'TOTAL: ISSUED BY:
OFFICE I