S 0243 - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELEL'ERICAL PERMI'C NO.
BUILDING DIVISION APPLICATION/PERMIT PLS UMBING-MECHANICAL 0243
BUILDING PB(3J=IDENTIFICATION V
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS.
N,
OWNER'SN E: 1' E: CON ORS A 1 N NIC CO IROL#
r ARCHtFEf7E 1 EER: LIC NO: A 1 El ..
G
cONTA P{{OV BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DIiCLARAT[ON Y. ELECTRIC PERMIT 1'EE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{Q{�,zCc) with Section 700Baf Division]of the Business and Professions Code,and my license ix RESIDENTIAL
FI- in full farce and affect. PERMIT ISSUANCE ❑smwi ❑KITCHEN REMODEL.
st-E.) License Lie. APPLIANCBS-RESIDENTIAL [I ADDITION Ll PLUMBING RE-PIPE
F Z ty Dme Cnnoacow
rnQa' ARCHITECTS DECLARATION MELT[-UNIT L1 STRUCTURAL
PANELS MODIFICATION
Z p Z 1 understand my plans shall be used as public records
0 pW UP TO 2IM)AMI!S ❑INTERIOR C]CHIMNEY REPAIR
r4fl
Licensed Professional 201-INXIAMPg IMPROVEMENT [J SWIMMING POOLS
XY .,.I OWNER-BUILIII?R DECLARATION OVER Ih(IIIAMP$ ❑BATH RIiMODIiI/REPAIR El DEMOLITION
yy S se 1 hereby aflimr that 1 um exempt from the Contractors License law for the
p(pLU following reaon(Smoom]6315,Biumexsand Professions Cale:Any cityor countySIGNS ELECTRICAL ❑OTHER
Y 3 4 which requims u permit to conswm,elteq improve,demolish, a repair tiny slrucwm
prior mats issuance,also requires the applicant fur such permit to file a signed statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions of the Coolractors License Law(Chapter 9
' CSO (commencing with Semlon]fKKDaf Divininn3ol the BuxinutenJ l'rnlossinns Code)or TEMV METER OR POLO INST. COMMERCIAL
G ly eC that he is exempt therefrom and the Iasis for the alleged exemption.Any violation of ❑ W BLDG/ADDITION ❑UIiMO1.ITION
trXl Wy
Section 7031.5 by any applicant for a permit subjects the applicanun a civil penalty of PoN'ER DEVICES FFNANJ. ❑FOODSERVICE
FS=Crte come(hon five hundred dollars($51X1) IILJ-IMPROVEMENT
❑ 1,as owner of the pmpeny,or my employees with wages as their sole abmpemm�ion, SWIMMING POOL ELECTRICfs
Sex will do the work,and the structum is not intended or offered for sale(Sm. Business OTHER
{D � and Professions Code:The Contactors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' property who builds or improves thereon,and who does such work himself or through
hit own employees,provided that such impmvemelns are not intended or offered for NEW RESIDENTIAL ELECfR tTMAU ,
sale,IL however.the building orimprovement is sold within one yeurof completion,]he SQ,FT.Ell AREA SISQ.1T.
mosm-builder will have the burden of proving that he did not build or improve for par-
Few of salt.).
❑ I,as owner of the prapeny am exclusively contracting with licensed catraemrs lo 1tmmtmmte gram,(Sec]044,Besinessand Pmfessiaas Cade:)'me C.—cmrsLi- - - Aase Law does not apply to an owner of property who build ur improves thereon,and QTY PL BING MITwho commit(or such projects with a eunoaotons)licensed pamman to theeomracton
License Law. PERMD .SCA
❑1 am exempt under Sec. ,R&P C for this reason
ALTER-DRAIN VL - .R HiA) VALUATION
Owner Dam �k
• WORKERS COMPENSATION DECLARATION BACK FLOW PROTE DE rl.lJrClY� h,
1 hereby affirm under penalty of perjury one of the following declam.iens:
❑ Ihow unit will...main u Certilicateof Consent mself-insure for Worker's Camper. DRAINS-FLOOR,ROOF,AL2. CONI STORIES 'TYPE CONS'fRUC'HON
satins,as provided for by Section 37W of the Latour Code,far the gerfaamence of Ihe
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensndun Insurance,m required by Section
3960 ofth Iatom Code,for the performance of the weak for which]his permit is iswed. GAS-EA.SYSTEM-I INC.4 OITITETS OCC.GROUP APN
My Werke ane 'o c er'r 77,,nd Policy 0 her
�,¢//�
Carrier: �fllot,Nn.Wq{RS' GAS-F.A.SVSTEM.OVF.R4(EA7
CERTIFICATE OF E%:M )N FROM WO ER GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSA'aION INSURANCE BUILD 1 N 1£E
(This xcedon need not becomplemdlf the permit is forum hundred dollars($1X6 GRHASETRAP
or less.) I'LANCHIiCK FEL?
I certify that in the performance of the work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FIT
not employ any person In any runner so as m become subject to the Worker..'Compen- ENERGY PEE
0Z ration Laws of Califomia.Date WATER HHA'ITR WIVENTIFLECfit GRADING '
Z p Applicant -
i.y h NOTICE 10 APPLICANT.If, for making this Cerilicac of Exemption,you should WATER SYSTEMaREATING SOILS ItiE
hecomewhjeem the Worker's Compensation provisions of the liber Code,you most
UJ fanhwith comply with such Provisions or this gambit shall be doemet revoked. WATER SERVICE
Q
p" CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.1T. PAID Done Rcceipta
V 0 (hereby ofar�a that is a consonalion lending agency far the performance of
[yr the work for which this pecan,is issued(Sec.3097,Civ.C.)
p L) ISndcrs Name T(TTAL
Lkl Lendce,Address TOTAL:
1 minify that I have read this application and state that the ahnve inform.......is BUIhDING PEE
ren cmnem.I agree m comply will,all cily and county ordimmecs and state laws relating to Q'I'Y. MF.CHANICALPERMIT FEF.
V Z building construction.and hereby malsorim represcreaives of this city to enter upon the SIi1SMIC FEE
rex aMrve-mentioned property for inspection puiposes. PERMIT ISSUANCE ELECTRIC
(We)agree to save,indemnity and keep harmless Ihe City of Cupenino against
liabilides,judgments,cone and expenses which may in any way nomme against said City ALTER OR ADDTO MECH. PLUMBING
inconsequent It gma]ingofthispe
AP'LICAN' NI rRSTANDS AND LI.COMP ITH ALLNN- OINT AIR HANDLING UNfC(TO 10.(XI6CFM) MIiCHANICALFEE
SOURCE GUL TI NS. /
' AIR HANDLING UNIT(OVER IO."CFM) CONSTRUCTION TAX
Signe. of Applo.ml/Cogracma Date EXHAUST GOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building nocapantsuve m handld
e to material HEATING UNIT ITO 100.000 BTU)
as defined by the Cotonimo Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(o)P HEATING UNIT(OVER](IQ(XXl BTU)
❑yes ❑Nn VENTILATION FAN(SINGLE RESIDI PAID
Dole Receipt X
Will the applicant or Wrote building occupam use equipment or devices which BOILER-COMP GHP OR Hat,"BTU)
emit hanad..ux air mmmmim moi as defined by the Bay Area Air Quality Management TOTAL:
District' BOILER-COMP(OVER 1(X),1100 BTU)
E]Yes ❑No
I have real the mournous imbmrials requirements under Chapter 6.45 of the Cali- AIR CONDITIONER ISSUANCE DATE.
fnmia Health&Safety Cade.Sections 25505,25533 and 25534.1 umlentand(hal if the NEW RESIDENTIAL MECIL SQ.FE
building does not eumittly have a tenant,that it is my responsibility to notify the mcupum
of the mauirememe which must be met prior to issuance of a Cenifienw of Occupancy.
Owner or umhadud.,car Date TOTAL: ISSUED BY:
OFFICE