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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING - ELECTRICAL.PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
NO.
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
/D lid 9/2-1Cl4 PL,
?i'?Shc
OWNER'S NAME: PHONE:
CON'TRACTOR'SNAME: /Z0fLIC
�H%l n/jLi .S-bTci
NIC
CON'fROLM
ARCHITECT/ENGINEER : LIC NO:
ADDRESS:
i 2 s A0.4 -rd CA /We
CONTACT: PHONE:
BUILDING PERMIT INFO
r_(_Vn a_JTV- 0O O
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELEQ PLUMB M
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
ISSUANCE
with Section 70dT of Division 3 of the Business and Professions Code, and my license is
Int fail force and effect.PERMIT
67 40
RESIDENTIAL:
❑ADWL ❑
APPLIANCES — RESIDENTIAL
L ice Class _ Lic.a
Date Contras �V
ARCHITECTS DECLARATION
1 understand my plans ,hall be media; public records
PLUMBINREMODPE
❑DDITION ❑LUMBING RE -PIPE
❑MUI.TI-UNIT ❑STRUCTURAL
MODIFICATION
PANELS
UP10200AMPS
El INTERIOR ❑CHIMNEY REPAIR
PROVF.MENT 0SWIMMING POOLS
Licensed Professional -
211-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
Following rwsom. (Section ]0315. Bminess and Professions Gude: Any city ,, county
TH REMODEIJRIiPAIR ❑DEMOLITION
OTHER
OVER IB(NIAMPS
SIGNS ELECTRICAL
which requires a permit to roriti,L m m, improve, demolish, w mpoir any swclum
SPECIAL CIRCU UUM ISC.
prior to is issuance, also requires the appliwm for such permit to file u signal statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(command, with Section lOW) of Division 3 of the Business and Professions Cade) nr
TEMP ME HER OR POLE INST.
COMMERCIAL,
that he is exempt therefrom and the basis for the alleged estimation. Any violminn or
❑ NEW BLDGIAODITION ❑ DEMOLITION
POWER DEVICES
06
Section 7031.5 by any applicant for a Permit subject the applicant to a civil penalty of
not more than five hundred JNlars ($.500).
❑I, as owner of the property, or my employees wish wages us theirsnlecompenmlinn,
will do thework, and the structure i, nnl intwdr4 orofiered for sale(Sec. ]1W4, Rosiness
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
1
SWIMMING POOL ELECTRIC L
and Prolessions Code: The Contractor's License Low does not apply to an owner of
OUTLETS — SWITCHES — FIXTURES
pmpety who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such improvements we not intended or oflemd for
sale.If, however, thebuilJing orimprovemem is maid wbhin oneywr of comalelion,the
NEW RESIDENTIAL ELECTS SQ Fr,
SQ. PT. FLOOR AREA $ISQ. Er.
owner -builder will have the burden of proving that he did not build or improve for put-
p
Anse of sole J.
El 1, as owner of the property, am exclusively contracting with licenaol ase maore In
% I ID
TOTAL:
construct the project (Sec. 7044, Business and Professinm Gula:) The Contractor's Li-
���
c se Law does not apply to an owner of property who builds or improves thereon,
QTPLUMBING PERMIT FEE
Y
��
DECID
whocommas forsuch proJm¢ with a coutmcrorSs) licensed putaamnt lathe Contractor's
HC4 (y
/�
PERMIT ISSUANCE Cur
License law.
❑ 1 am exempt under Sec. R & P C for this reason
_
or sur
,11ATION
ALTER —DRAIN & VENT— WATER (EA)
Owner Dam
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. UEVICF.
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS— FLOOR, ROOF. AREA, COND
❑ I have and will maintain aCenlficatoof Coreent to self -insure for Worker's Compen-
cation, as provided for by Section 3700 of the lobe Code, for the performance of the
STORIES
TYPE CONSTRUCTION
won r which this Permit is issued.
FIXTURES—PER ITAP
hove and will maintain Worker's Compensation Insummm, vs required by Section
37M oflhe Labor Code, for the Performance of the work for which this permit is issued.
'GAS — EA. SYSTEM-] INC. 4 OUTLETS
OCC. GROUP
ADN
My Werke Gnrlyegyu lnaya�esppi poky IS.and Put 'a, nu6`WX_gg
Cartier: � //ff'',, `` !!�— NNVV
GAS — EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEANDUSTRI. WASTE. INTERCEPTOR
BUILDING DIVISION FEES
(This aecdon Deed mtbe completed if Nepermit is future hundred dollars (Sled)
or tax,.)PLANCHECK
GREASETRAP
PLG
I certifyther in the perrormance afthe work forwhich this permit is issued, l shall
not employ any person in any manner so as become subject becomsubject to the Workers' Compen.
SEWIiR— SANITARY —STORM EA. Am FT.
ENERGY FEE
WATER HEATER WNENTIELECTR
GRADING FEE
sation laws of Culimmia. Date
Applicant I
NOTICE TO APPLICANT: If, after making this Cenificme of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
WATER SYSTEMITREATING
SOILS FEE
PoXhwaharmply with such provisions .,,his permit shall he Jeemedrevnked
WATER SERV ICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a eonstmetion lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ, FT.
PAID
Dale Receipt It
the work for which this permit is issued ISca. 3097, Civ. C.)
Lenders Name
-
TQTA
Lenders Address
TOTAL
1 owify that 1 have read this applicalion and sone Nal the above information is
BUILDING PGE
QTY. MECHANICAL PERMIT FEE
entreat. I agree to comply with all city and only oninances and slate laws rdalingoo
building commiainm and hemby both ... izerep c,calmive—I'mis cloy to enno,am live
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEB
above-menlinned pmpeny for Inspection p.,.,a,.
(Wo) agree to save, indemnify and keep harmless the City of Cupenirm against
ALTER OR ADD TO MECH.
PLUMBING FEE
Iiabililies,pid,donts, consand expenses which may in any way acemeagainstsaid City
in consequence mf the granting of this permit.
AIR HANDLING UNIT (TO 10,0) CPM)
MECHANICAL. FF.E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicauctmmetor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION ME
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle haxmdaus mormal
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Code, SecOon 25532(x)1
HEATING UNIT (OVER 10(1000 RTU)
❑Yes ON.
PAID
Date ReceiptN
VENTILATION FAN (SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which
emit hazel air contaminants as defined by the Bay Area Air Quality Management
BOILER —COMP f?HP OR 100,003 BTU)
TOTAL
BOILER— COME (OVER P00," BTU)
Cranial?
❑Yes 7 N
AIR CONDITIONER
I have read the hvashm, materials requimmnnlc under Chance 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQ, Pp.
fomis Health & Safety Code, Sections 25505, 255]3 and 25534. I understood that if the
but dmesinc er enlly havcatenan4 shat it is my responsibility ro notify the mwupam
oft quiremems which 11ZJ,(ie. am Prior to issuance oft Ceni sate of Occupancy.
-Za-9�
ISSUED BY.
TOTAL-:
Ow raulhorized engem Dale
V
OFFICE