B 0217F-
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
I h.reny aRrm that I vat licensed anger provisions of Chapter 9 l tvmmense is
with Section 71g0)uf Division3of the llutinets and l'ndessions Coda trialmy license is
in full force and �e_fi�mpL} �
I.ieen Lie p —1ULA
BUILDING - ELECTRICAL.
❑SFDWL
F-13RMI I' NO.
BUILDING DIVISION APPLICATIONMERMIT
PLUMPING -MECHANICAL
11 11
SOOO 1
420217
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Licensed Pmfcssimmnl
OWNER.BUILDER DECLARATION
Liu 1.DING PROJEC7IDEN TIFICAT'IUN
CCHIMNEY REPAIR
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BUILDINGADDRESS:
>rRATH REMODELfRI!PAIR CDEMOI.IT'ION
C OTHER
SANITARY NO.
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APPLICATION SUBMI I9'At, DATE
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his awn employees, provided Ina, such improvements am no, intended or offered for
OWNERS NAME:
Pf10NE:
EPN I RAC( R'S NAME: LIC NO'
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NIC
CONTROhX
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❑
HITE(TUEN, ERR: LIC NO:
ADDRF S:
52 L.
CONTACT:
PHONE:
HUIL171NG PERMIT INFO
en.ac Law does not apply to an owner of property who Indictor improve. thereon and
❑ COnSultant FeeS Paid by Applicant (Initial)
BLDG
ELS PLUMB M ,
License Law.
I am exempt under Sm. ,11& P C for this reason
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I h.reny aRrm that I vat licensed anger provisions of Chapter 9 l tvmmense is
with Section 71g0)uf Division3of the llutinets and l'ndessions Coda trialmy license is
in full force and �e_fi�mpL} �
I.ieen Lie p —1ULA
❑SFDWL
1�61UTCIIEN REMODEL
Umc Cmnmemr�
/ ARCUI'fECT'S DF.CfARAT ION
1 understand my plan. shall be used as public mcards
❑PLUMBING RE-1]PE
❑MULTI -UNIT
❑STRUCTURAL
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Licensed Pmfcssimmnl
OWNER.BUILDER DECLARATION
11 INTERIOR
CCHIMNEY REPAIR
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1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031 5, Beams, and Professions Code: Any city or county
which requires a permit in construct, alter, improve, demolish or repair any structure
F,ior to its issuance, also requites the applicant for such permit to file a signed statement
that he is licensed pursuouno the pros isions of the Con,mnors license Law (Chapter 9
>rRATH REMODELfRI!PAIR CDEMOI.IT'ION
C OTHER
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(commencing withSecrion 7gg7 of DiAkiue3ofthe Musings. unit Pralcssiuns Code) or
he is exempt therefrom and the basis for Lha alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
e than me hundred dollar, ($500).
me
3h I,.sose".1lhepn'peny,army enytmyces with wages ns their sale cotnpensa,iun.
will do the work, andlhestrucmre Isnot intended or offered for ade(Sm. 7044, Business
and Professions Code The Coneracmes License Low does not apply m an owner of
property who builds or improves therwn, and who dues such work himself or through
his awn employees, provided Ina, such improvements am no, intended or offered for
sale. IL however, the building or impmvem,m is sold within one year of completion, the
ilder will have the burden of proving that he did not build or improve for pur-
ponenta
se of sale.).
❑ L as neper of the propeny, am exclusively contracting with licensed contractors I
mswct the project (Sec. 11W, Business and Professions Curb:) The Commerce, LI-
en.ac Law does not apply to an owner of property who Indictor improve. thereon and
QTY.
who c .anis for such projecle with amourvelor(t) licensed pursnvn„m the Connector's
License Law.
I am exempt under Sm. ,11& P C for this reason
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affimt under penalty of perjury one of the following declarations:
C I have and will and main a Cerifmmm of Consent n self-insuareRrWorkers Compen-
sation, as provided for by Section 37W of the Labor Code. for the performance of the
work for which this pemtit is issued.
1 have and will maintain Workers Compensation Insumoce, vs required by Section
3700ofrhe Labor Gde, home Ne work forwniah this permit is issued.
My Work 's Cy tkIasumnce cartierand Policy Pum bra re
Comer. �"Ztr� CT,'-)I'REXEMI'I'IONPolicy
I FROM WORKERS'
CERI IFCOMPENSATION
INSURANCE
(Thin section need not he completed tithe pemhil is forme, hundred dollars (SIBB
or less.)
1 candy that I life perfornmace of life work lin which this pennh Is issued.I shall
not employ any person in any manner so as to become subject to the Workers' Compete
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OApplicant
ration laws of California, Data
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NOTICE TO APPLICANT: If, vRef making this Card Imam of Exemption, you should
become subject o the Workers Compensation provisions of the labor Code. you must
fonhwlth comply with such provisions or this permit shall be deemed revoked.
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UQhereby
W. Htea
that emisacomwclending agency for the performance of
CONSTRUCTION LENDINGAGENCY
work for hich his permit is issued (Seo. 3097, CivCJ
Lenders
C) U
e
LenderAddress Lender's Address
OJ
fy
gree that 1 have read this y .nal cion and nate that the above l information is
ding ogre, ong rad with Ill ehy mist county outman this stem laws miming
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of this city to enter upon the
c i of
building cnnstmctian,and hereby
!.Tinspectionzereprescmaives
above -(We)
greeed top mr,ri-ty an keepha.
(We) me m soil, indemnifyex,o and keep hay an the City Calico!ics, City
,, io re
liabilities, cont and cxPensev which may In any wuY neem, vgeins,.vaiA City
,
in consequence of the granting of this permit.
XRTTC,T T UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building mcuccom Wore m handle h.zandous material
as defined by the Cupanino Municipal Code. Chapter 9.12, and the Health and Safety
Coda Seen i 25532(x)'
❑Yes MI Nn
IWill the applicant or future building occupant use equiptnent or devices winch
n hazardous air contmninanlx as defined by the lily Area Air Quality Management
Distract” �/'
Ely"@�No
I hove fund tea hazmdo t, material, mimmments under Chapter- fi95 of the Culi-
fomia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the
mgdms urremly have. factor,Of., it ism, resµmsibility to notify the oacupanl
u he nxi,uammtwhich must mine, prim to ... arnmofa Cm3ii'li'v4ecenpancy.
ELECTRIC PERMIT
PERMIT' ISSUANCE.
APPLIANCES - RESIDENTIAL
PANELS
UPTO200AMPS
201-1000 AMPS
SIGNS IiLEC'I R]CAL 17
SPECIALCIRCUITIMISC.
TEMP. METER OR POLE INSX
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLEIS-SWTI CHES-FIXTURES
NEW ]IRS IDEN' HAL P.LEC'I'R SQ It
PLUMBING PERMIT I
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (HA)
BACK (LOW PROTECT. DEVICE
DRAINS -FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS -IIA. SYS'I EM -1 INC.4 OUTLETS
GAS - HA. SYSTEM OVER 4 (EA)
GREASIIINDUS'I'RL WAS 117 INTERCEPTOR
GRF.ASETRAP
SEWER -SANITARY-S'IORM EA. 200 FT.
WATER []EATER W/VENT/ELEC R
WATER SYSTEMITREATING
WATER SERVICH
NEW RESIDENI'ML PLMB. SO14.
MECI IANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO NI
AIR HANDLING UNIT (TO 10.000 CPM)
AIR HANDLING UNIT (OVER IR000 CPM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT ('f0 100,000 BTU)
HEATING UNIT (OVER 100,000) PTU)
VENTII.A'TION FAN (SINGLE REBID)
HOILER- COMP (3HPOR 100,000 RTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. M
OFFICE
FEE
I
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
1�61UTCIIEN REMODEL
❑ADDITION
❑PLUMBING RE-1]PE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
11 INTERIOR
CCHIMNEY REPAIR
IMPROVEMENT
El SWIMMING POOLS
>rRATH REMODELfRI!PAIR CDEMOI.IT'ION
C OTHER
COMMERCIAL:
C NI7W BLDG/ADDITION
C TENANT
IMPROVEMBNT
[]OTHER
lJ U SQ, PR FLOOR AREA
, -,d
C DEMOLI TION
❑ FOOD S17RVICE
$ISQ. ET.
n A \ T-
01 01
BUILDING DIVISION FEES
PLANCHECK Ili[?
ENERGY FEE
GRADING THE
SOILS FEE kA
PAIDv
HrLLe Receipt M
�\ 1 TOTAL:
FEE .-. SEISMIC
PLUMBINGFEE \
MECHANICAL FEE v
CONS1'RUCTION'1'AX
HOUSING MITIGATION FER
PAID
Data
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