29175APPLICANTTO FILL IN. INFORMATION WITHIN RED
CITY OF CUPERTINO a1- _
BALL POINT PEN
PLUMBING
FE-
29175
l s9to.
OFFICE
❑ Consultant Feu Paid by Applicant (Initial)
SLUG EL PLUMB"' MECH
EDLICENSED
CONTRACTORS DECLARATION
1 hereby "(firm thin 1 am licensed antler provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Section 7M) of Division 3 of me Business and ProfesainnaGNe. and my license is
in fallfene Cloaal ethic. .5 t77p��
License Clns, a•J Lic.k —.J G
pstLr-- Contractor
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE.
PERMIT ISSUANCEIDL
APPLIANCES -RESIDENTIAL
.ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
PANELS
t
UP TO 2W AMPS
RIOR [I CHIMNEY REPAIR
1 ROVEMENT
❑ BATH RF.MODFUREPAIR ❑DEMOLITION
[]OTHER
Licensed Professional.201-IIXp
OWNER -BUILDER DECLARATION
I hereby affirm that 1 em exempt from the Contractor's License Law far the
following reason. (Section 703 1.1, Business med Pmmodons Code: Any city or county
which requires a permit to conxwet alter, improve, demolish, or repair any structure
AMPS
pVF.R IODIIAMPS
SIGNS ELECTRICAL.
prior To its tax uance, also mild., the applicant for such permit o file it signed statement
That he is licensed pursuant tp the provisions f,he Contmcors License Law (Chapter 9
SPECIAL CIRCUIT/MISC. S
TEMP. METER OR POLE INST.
COMMERCIAL:
ED BLDG/ADDITION ❑DEMOLITION
(commencing with Section 7")of Division 3 of the Business and Professions Cale)or
thin he is exempt therefrom and the basis for the alleged exemption. Any violation of
POWER DEVICES
Section 70713 by my applicant Porti permit subjects the applicant toacivil penalty of
.at mare than five hundred dollars ($50T.
E] 1, as owner of the properly, or my employees with wages as their sole compensation.
will do me work, and thesnucture is nm imenmcitur Rered for sale (Ser. 71W4. Business
and Professions Code: The Contractor's License Law does not apply to an owner of
'OTENANT ❑ FWD SERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES lO
property who builds or improves thereon, and who does such work himself or through
his own employees, provided thin such improvements me not intended or oRered for
sale. If.however, the building or improvement is wild within one yearefcompletion, the
NEW RESIDENTIAL ELELTR SQ PT. '
SQ.FT.FLOORAREA
5/SQ. PT.
ownerbuilder will have the burden,(proving that he did not build an improve for pur-
pose orimic.).
-
❑ L as owner of the properly, min exclusively contracting with licensed cmaracmn to
construct the project (Sec. 7U , Business and Profeuiuns Cole:) The Conuacors
�1
,
Genu law does natupply marrowtterofpmperty who build, or improves thereon, and
QTY. PLUMBING PERMIT FEE
4 1 a„
whocantmetsforsuch projects with a contractods) licensed punuanna the Conuacors
License law'
❑ Iamexcmptunder Sec. -,B&PCforthispmom
I �D
4*
•,
PERMIT ISSUANCE
Owner Dam
ALTER - DRAIN & VENT -WATER TEA)
V" !ON
E•
hLGrV
Cry
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury tine of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
1 base and will rommain a Cenificareof Consent m sel6Itim. for Worker', Compen-
kin
,lion, as Provided fos by Section 37M of the Labar Cale, for the performance of the
RI
STOES 11 (�
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
I1 have and will maintain Worker's Compensation Insurance, as required by Section
Crd e, Rrth SpeefonnancCfufrNepolicy �prlwhi`IiBtGhis permiti suet.
OCC. GROUP-
APN
GAS-FA.SYSTEM-IINC.4OUTLEfS
�C4y Workersabor
Comer. No.:.(.,+zfZY>
GAS -EA. SYSTEM OVER 4(EA)
a�Policy
CHRTIFICATF.OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FE -M'
(This suction need not be completed ifthe pmrut is foroae hundred dclims(SIW)
or less.).
OREASETRAP"
PLANCHF.CK FEE
Icerlify that in the perfonnancrosfam work for which thispermit is issued, l shall
rim employ any pcaon in any manner so as to become subject m me Workerd CourtENERGY
SEWER - SANITARY - STORM EA. 2W FT.
FEE
WATER HATER W/VENT/ELECTR
GRADING FEE
amion Laws cf Califumia. Date
Applicant
NOTICE TO APPLICANT.If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of me Labor Code, you must
WATER SYS'TE!,VTREATING
SOILS FEE -
forthwith comply with such provisions or this Permit shall be deemed revoked. -
WATER SERVICE
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that them is a construction lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ. FT.
PAID _
Date Receipt#
me work for which this permit is issued (Sec. 3097. Civ. C.)
I
-
Iendera Name
TOTAL:
lender's Address
BUILDING FEE_
I scrofy that 1 have read This application and state ma the above immarminn is
QTY. MECHANICAL PERMIT FEE
SEISMIC FER
ommet. l agree m comply with all city and county ardinances"ad vote laws relining o
building construction, and hereby authorize representatives of this city to enter upon the
PERMIT ISSUANCE
ELECTRIC PEE
shove -mentioned progeny for inspection mrpmes.
(We) ,give o save, indemnify said keep hornless the City of Cupenina against
ALTER OR ADD TO MECH.
liabilities,judgments, cups and expenses which may in any way accrue against said City
in consequence of the granting ofthis Permit -
PLUMBING FEE
AIR HANDLING UNIT (TO 10,QW CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WIT COMPLY WITH.ALL NON -POINT
SOU E .GULA NS. (I
AIR HANDLING UNIT (OVER I0,000 CPM)
CONSTRUCTION TAX
•Sigwtre o(ApplicanUCnntommr
E
HAZARDOUS MATERIALS DISCLOSUR—
EXHAUST HOOT) (W/DUCT)
HOUSING MITIGATION HE
HEATING UNIT (TO IW,IX111 BTU)
Will meapplicautorfnurebuildingacaip"mume r handle huolm, mmerim
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cale, Section 25532(a)?
HEATING UNIT (OVER 1 W,13W BTU)
(:1 Y. FIN.
Will the applicant or (anti" building occupant use equipment or devices which
thadous air contaminants as defined by the Bay Area Air Quality Management
em
icC
❑Yms 'ONo
PAID
— a
�I m Receipt
VENTIIATION PAN (SINGLE RESID)
-
BOILER -COMP (IHPOR-I W,(NgIBTU)
TOTAL:
BOILER -COMP(OVER IW,(XIO BTU) t
AIR CONDITIONER
I have readthe hazardous materials requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT. '
_
font. Health & Safety Cade, Sections 25505, 25533 and 25534.1 umdermard that if the
building dors nm currently have a mr.ru mat it is my respmtsibilay o comfy the occupant
ofthe requirements which must be met print to issuance of a Cernfcate of Occupancy.
r
'
ISSUED BY:
- TOTAL.
Owrar or improved! agent Dare
OFFICE