S 0423APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING - ELECI'RICAI. I'1iRMl i' NO.
CITY OF CUPERTINO APPLICATION/1'F,RMIT 1'LUN1IrIN0. A1RCIIANICU- S 0423
ItIJILDING UI VISION nnsr star. nu"o— un—sl H-ATuIN -
OFFICE
V
OWN R'S NAME: PHONE: —
CONTRALTDR:S NAME: LIC NO:
NIC
CUR I'ROLo
'AH
ID
APPE /ENGINEER: LIC Nil:-
ADDRE.
Ilrl
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CONTACT: PHONE:
BUILDING PERMIT' INFO
BIDE ELEC I PLUMH NIECE]
❑
❑ Consultant Fees Paid by Applicant(Initial)
LICENSED COMRAC' FOR'S DECLARATION
1 hereby affirm that I an licensed under provision of Chapter 9 (commencing
with Section 7000)ofDlv'ohn3oflha Businessland Profusion Cod[•,andnty prep, is
in full force and
License Clo. , [ Lima �-
Comommr
QTY ELECTRIC PERMIT FEC
JOB DESCRIPTION
RP.SIDENTIAI:
❑SFOWI. C3 KITCHEN REMODEL
❑ AUDI T[ON ❑PLUMBINGRE-PIP17.
❑STRUCTURAL.
MOIIIFICAMON
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT CSW'IMMINGPOOI.S
[I BATH REMOD• RE 'Al [I DEMOLITION
❑OTHER
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1117RMI'I ISSUANCE
APPLIANCES-RESIDEN'1'IAI,
ARCHITECTS DECLARATION❑MULTI"UNIT
I indersmndmy plans shall he used as public records
Licensed Profeuslonal
OWNER-HUILDER DECLARAI[ON
1 herchy efftmt that I am exempt's from the Cmdowt.License law for the
following reason. (Seaton 7031.5, Business and Powfi ions Calc: Any city nr county
which requires a permit it) construct, alter, improve, demolish or repair any structure
puilits icwanc[.aHo ropino, he ittodmimfor such pemtino fie itoloodsmtiamem
Am
that he is licensed prrsuanno the provisions of the Contractor's License Law (Chapter 9
PANELS
UPTO200AMPS
201-1000AMPS
OVER 1000 AMPS
SIGNS I?LELTRICAL
SPECIALCIHCUITIM ISC.
S y o C
ro
FZY
tis
Wand
(commencing with Section 7100) of Division 3 ofthe Business and Professions Come) or
that he is exempt therefrom ad the basis far the alleged exemption. Any violation of
Senbn 7031.5 by any applicant for a permil subjects theoppl'annu,, a eivll punaltyuf
not mare then five hundred dollars(S500).
Fl conas owner ofthe progeny, or my employees with wagesastheirsole nnnpens:ninn,
will Ar the work, and the structure is not intended or oucred or sale (See, 7(W4. louvres,
Professions Code The Contrecmr's License law does not apply to un owner n(
who militia, improves thercuri. and who Ones such weak himself or through
']'EMP. M ETER OR POLL. INS' I'.
COMMERCIAL:
El NEW BLDG/ADDITION C1 DEMOLITION
❑TENANT [I TOO[) SERVICE
IMPROVEMENT
El OTHER
POWER DEVICE
SW ING LELIiCTRIC
O-SWITCHIS-FI%TUREti
property
his own employees, provided that .such improvements arc not intended or offercfor
sale. If, however. the building orireprovement is sold wifin one year ofcompliame,the
N I SID 'FI FLECTR SQ IT.
.sl
SQ. IT. FLOOR ARRA
SISQ. FI'.
owner -builder will have Ne harden of proving that he did not hadd or impnwe for pur-
TOTAL.
pose of sale.),
I, n owner of the property, am exclusively contracting with licensed common, to
nnuvue the p ]ate Ise, 71,14, Business and Prof ..am, Codcl'III, Gmtmeorn Li-
cense Law does not apply to im owner of properly who builds or improves thereon, and
who contrcn.for such projecu with a contmemgs) licensed paroma,,the Comrucmr's
p
P�
1h
{'']. -
QTY �U B OPE FEE
-
PERMIT ISSUAN
License Law.
❑ I em esempt under Sec. . B & P C fur this reason
7 Q
a �I
Owner Date
ALTER- DRAIN& :NT TERMA)
ss,11 r(,,. VALUAT
?d0
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROIECC DEV
1 hereby affirm under penalty of perinD one of the following'feclarmions:
sJ
STORIES
TYPE CONSRUCTION
❑'I have and will maintain aCerificam ofComent melt -insure for Worker's Counties"
ration, as provided for by Section 37M of the Labor Code, for the performance of the
work for which this permit is issued.
DRAINS- FLOOR, ROOF AREA, CONE
FIXTURES - LITR'FRAP
X1 have and will maintain Workers Compensation Insurance, n required by Section
. 00 of the Lamar Ced., for the performance of the work for which this permit is issued.
GAS - HA, SYSTHM- 11 NC. 4 OU'U_16fS
OCC. GROUP
AIN
Ca Worker's Comrynatlon In •c Nor: nnntberarc:
j �-/�y,/ Fruit,
Carrier. n oNor: 7nS'Ll
---
GAS -EA. SYSTEM -OVER
GREASOINDUSTR-WASTEINTERCEPRIR
WORKERS'
-CERT' CAE 'EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE:
BUILDING DIVISION PI?ILS
(This cation need not me compined if the peasit is4nonehundrcd dnllers lSllOp
or us'.)
GREASE 'IRAI"
PLANCHECK FEE
SEWER - SANITARY -S'] ORM EA. 200 FT
P.NI3NGY FEE
I certify that inhe perforranceofdhe work for which thispaint, is issued. [,hall
not employ any person in any manner so as to become subject to the Workers' Compere
WATER HEATER WIVCNTIF.I.ECTR
GRADING FEE
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7
sation Laws of Califaria. Date -
Applicant '
NOTICE TO APPLICANT: If, after n rking this Cesifnae of Exemption, you should
become subject to the Worker's Concentrationprovisions of the Estrin Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
ninn lng agency for the perfortnance of
Iherthy amen that there isamnwendi
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lenders Name
WATER SYSTEM TRHATING
SOUS FEE
WATERSERVICE
PAID Dam Receipt#
NIiW RESIDENTIAL III SQ, 17.
IOTA]"
'IOl'Ah:
Lenders Address -
BUILDING PEE
1 certify that I have read this application and state that the above information is
coorcct.I agree to comply with all city and county, ordinances and state laws relating a'
build,,,, arretmetlrn, and hmrehyailt... z m,wwnlatives nl' Ihl,cdty memerupon the
QTY' MECHANICAL PERMIT PEP,
SEISMIC FEEU .
PERMIT ISSUANCE.
ELECTRIC Ig1B
a
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hapless the City of Cupenho against
PLUMBING FEE all
liab'iities,judgments. costs and expcnn which may in anyway accrue againstaud City'
in consequence of the granting of this Ismail.
ALTER OR ADD TO MECH.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
AIR HANDLING UNI1'(I'O 101010 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER IB,IMO CIM)
CONS 'fRUC'TION TAX
Signature of ApplicienteContmctor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD UMMUC17
HOUSING MITIGATION FEE
HEATING UNIT (1011X.010 BTU)
Will the applicancor here bud Wing ove. ant.aore or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cadm-Scction 25532(n)^
HEATING UNI "T (OVER IakOIXI B'I'U)
❑Yea ON.
VENTILATION FAN (SINGLE RBSID)
PAID
Dem Hcceipfa
BOILER- COMPCEIBI OR 10i BTU)
WiII the applic nt I,,litmrc hnilding occupant use marcs t or devi . which
emit hanimmus air contaminants as defined by the Bay Area Air Quality Management
,TOTAL
BOILER - COMP (OVER 100,000 BTU)
Disuict7
❑Yes Fl No
AIR CONDITIONEREE
I have read the haearins nx,rim., requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MIiCH. SQ. FF.
fomia Health & Safety Cade, Sections 25505, 25533 and 2 EFI.1 understand that if the
building docs ma currently have a tenure, Nat it is my msponibilily pn owify the occupant
OFFICE