S 0101APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Ison,DING - ELEC I'RICA], PERMIT NO.
CITY OF CUPEHTINO PLUMBINC - MECRANICAL S 0101
BUILDING DIVISION API'LICA'PIONA'F:RM111T .11111.rar nenlE,r -r mevrmcnnaN
PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
I hereby zffinn that I am licensed under pan nions of Chapter 9 amnmenomi;
y0 with Seaion]0f10)Of Uivisinn7 of the Business radii &,,ions Cadaandmylmmwiz
me snot t. /�����
Y U ~ Licemc Class Lim. k ,
n 6 6 Datc Contractor
ARCHITECTS DECLARATION
r2 K 1 understand my plum shall W used as public recoml
t,`0
b W I'slosim Professional
OWNER - BUILDER DECLARATION
Y C Q I hereby of on Iban 1 am exempt from the Contractor's License Law for the
D i Uk. following mason. (Section ]( 171.5. Easiness and Pmessions Code: Any city Or county
3 W NQ which requires a permit to construct, alter, improve, demolish, or repair any stmmum
.] prior to its issuance, also requires the applicant formch Permit o file a signed ztaemmnt
� y that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
f on of the Business
and Profnsions Code) or
Q Section ]IXXI of Division aG0 Inimmcncing with sc 1
q o y Se, he is 0x1.11 IanyNrmn and the per fnsubj ct%thJ exemption. Any l faunann of load
rn Statione than five anydredd dollars ($500).
suhjcas the upPllcommuunit penalty ul
m more then five hundred dnllam y empl.
C I, as owner of the Pmpcny, nr my cmployms with wages as their tole compensation.
F. will do the work, and the structum is not intended or ollendl for sale lSec. ]IW,Uminers
63 ro and Professions Code: Itm Ctimmnor's License law does not apply to an owner of
pmpcny who builds or improves thereon, and who does such work himself or through
his own employee., provided the such improvements am not intended or offered for
sale. IL however, the building or improvement is sold within one year of completion, the
eomilder will base the burden of proving door he did ant build or improve far par.
Pula• of avle.).
❑ 1, as Owner of the property, am exclusively c mimmfing with licensed cnnuactors to
contract the pmjeca (Sce. 71114. Rasmus and 1'rol'es inal Cade:) The Cormaeasr's Li-
cense law does not apply to an awucr of property who builds or improves thereon, and QTY
who contracts for such pmjcas with a cononctor(s) licensed pursuant to the Contractor's
'License Law.
1 am exempt under Sec. . B & P C for this mamn
ELECTRIC PERM I'1'
PI2RMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANHIS
Up TO 201 AMPS
OVER IU00AMPS
SIGNS ELECTRICAL.
SPECIAL. CIRCUITIMISC.
TEMP. MEER OR POI'
7 W ER D1i110ES
SWIMMING
C'
OUTLETS- SWITCHES-
Owner _ Date s:
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penuhy ..f Perjury one of the following declaration
;'171,'fI1mLoW (have ponvidl for by etion 37M OfCnmmnl nl ode. tufe list ......sCompen-
as provided for by Section 7]00 Of the LoN1r Code. fonhe psdnmrana o[ the
or which this permit is issued.
ave and will maintain Workds Compensation Insurance, as required by Section
C, p. fimtheperfo anceofthewnrkmr hichthnpermitisiswed. ork n Pmranc caricroli Policy he)gry7 / / —�'7
CEk'rll9CAT17OF EXEMPIIONFRO WORKERS'
COMPENSATION INSURANCE
(This section need not be emadided d the permit is furore hundred dollars (S I W)
...less.)
(certify that inthe my of theworkfor which Nis permitis issued. lshall
not employ any person in any manner so as to beulmc subjm to the Worker.' Counter-
0 Z saloon Law, Of California. Date
Q Applicant
tiNOTICE TO APPLICANT: If. after making this Conilicam of Exemption, you should
become subject m the Worker's Compencamm Provisions of the Luton Coda you last
forthwith comply with ... It pro ....... or this penotit Shull he JCCmcd«vuk1
no CONSTRUCTION LENDING AGENCY
U p (hereby elfirm that there isaconstruction lending agency for PCdnnnmce of
U. F' the xmrk for which this permit is rsmed (See 1007. Co. C.)
O U Lenders Name
IU Loun cr's Address
ly 1 certify that I have mad this application and slate that the aMVC information is
y s rect. I agree to comply with all city and county ordinances and slate laws refuting to QTY
U z building construction, and hereby authorize representanve'of this city loaner upon the
above- mentioned property for inspection pullsocs.
(We) ages, to save, indcmlufy and keep hvnnkss the City of Cupertino tomin.a
Iiahilitics.juit ta,en.sts and expenses which may in any way accrue against said City
in Cansqucnce the granting.fthispermit.
APPLICANT .NDERSTAF}I)SAND WILT. COMPLY WITH ALL NON-POINT
SOURCE 'ULAIIONS/ /J a e I �/ - / - (_.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or lumm building occasion ..roc or handle hw.urdous material
as defin.l by the Cupeoinn Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section 2557200?
❑Yc: ❑No
L1 Will the applicant or future building occupant use equipment or devices which
, hvaduus air contaminant, as defined by the Buy Area Air Quality Management
District?
E] Yes El No
I have read the hvznrdom mamrials rcquimnents under Chapter 6.95 of the Cali-
fornia Health Be Safety Code. Scallions 15505, 25577 and 25577. 1 understand that if the
building does not currently have a tenant, that it is my reshonsibihty to notify the occupant
Of the.quimmcntr, which must be and poor us issuance of a Cenificam of (somfomy
Owner or authorized agent [late
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WAHiR LEA)
BACK PLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOIT, AREA. COND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM -I INC. J OUT LIiS
GAS - EA. SYSTEM -OVER 4(EA)
GRUASH/I NDUSTRL WAS 11; 1 I I FRCF,ITOR
GRVASIi'I'RAP
SEWER - SANITARY - STORM EA. 210 FE
WATER HEATER WHEN- FIELECTR
WATER SYSTEMITREATING
WSJ fit SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER 0R ADD TO MECH.
AIR HANDLING UNIT (TO 10,0I4)CFM)
AIR HANDLING UNIT OVER W.(W CFM)
EXHAUST HOOD (WOOL CT)
(HEATING UNIT TO 100,000 IT U)
I I F TING UNIT(OVER II India p IITU)
VEN'ILATION FAN (SINGLE RESID)
BOILER - COMP CHPOR 100,000 BTU)
BOILIER- C(MP(OVER 100,000 FIT U)
AIR CONDITIONER
NEW RESIDENTIAL MUCH. SQ, FT.
FEE
FEE
FEE
GQQ
N/C CON 'I ROI.or
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWI-
❑ KITCHEN REMODEL.
❑ADDITION
C3 PLUMBING RE -PIPE
❑NIUI.TI -UNIT
C3 STRUCTURAL
❑ IN'I'FRIOR
/p•�ODIFICATION
I�LII SIN 7,Y REPAIR
I MPROVEMEN'1'
/`] SWIMMING POOLS
❑ BATH REMODIEIJREPAIR
❑ DEMOLITION
❑ arifER
COMMERCIAL:
❑ NEW HLDG /ADDITION ❑ DEMOLITION
❑TENANT' ❑FOOD S17 .R VICE
IMPROVEMENT
❑ OTHER
LSQ, FT
N -9 10.9
Ur cUPEHT1N0
BUILDING DIVISION PHES
PLANCIfE Igili
ENERGY FEE
GRADING FEE
SOILS FEE
PAID ._
BUILDING IT
SEISMIC (ZEE
F.LECI'RIC141
PLUMBING II
CONSTRUCTION TAX
HOUSING MITIGATION FEE
�PAID�
Da¢ RccceiptM
I (YI'AL:
DATE