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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO PLUMBING - NLECIA
BUILDING DIVISION APPLICATION/PERMIT rINGPROJECTING :DEN
BUILDING YNOJECI' IBEN'
ILDING ADDRESS:
//as-& Agfa -5 grafts Ct'
LIC NO:
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARXISONQTy
I hereby affirin that 1 um licensed under provisions of Chapter 9lumtmencing
with S«tion 90l Division 3tithe Businessland l'mfcwhm, Cede. and my license isPERMITISSUANCE
his own employees, provided thin such improvements me res Ince or
ELECTRIC PERMIT
in full force and effect.
APPLIANCES — RFSIDENTIAI.
License Class Lic.0
Doc Contractor
ARCHITECTS DECLARATION
PANELS
1 understand my plans shall he used as public records
UPTO 200 AMPS
]licensed Professional
201-IDX)AMPS
OVER IIXXI AMPS
OWNER -BUILDER DECLARAOON
I hereby affirm that I it, exempt from the CormOmr's License Law for the
following reason. (Section 7031.5. Business and Prohnsions Codd Any city or county
which requires v permit to comwct. alar, improve, demolish, or repair MY slmcturc
prlor,o its issuance, alsorequires theapplicanl TO,aich Rconomfile.,ilned xmmmenl
that he is licensed Pursuant to the provisions Of the Contractor's License Law (Chapter v
(commencing with Section 7000) of Division 3of the Business and Professions Code) or
that he is exempt Ihercfmnt and the basis for the alleged exemption, Any violation of
Section ]091.5 by any applicant for a permit ohjmfs the applicant m v civil penalty of
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES s
n morn than Eve hundred doll... (P500).
1, as owner of the propcny, or my employees will' wages as their sole contpensutlon,
will do the work, and thestmnum is not intended or o1cred for sale (Sec.](k4, nosiness
and Professions Cede: The Cornea s License Law does not apply,, an owner of
pmptmy who builds Or improves Thereon. aml who does such wad himself Or through
MN offered f or
NIiW RISIUIiNTIAL ELECTR SQ IT.
sale. If, however. the building or improvement is sold within one year of complmion. dW
wner-builder will have the burden of proving that he did not build or improve for pur-
rose Of sale').
❑ 1, as Owner of the propmty, an, exclusively cmmacnng who licensed nmuucn,r. m
construct the S, ject (See. 711`11, Business and probes"ans Cedc) The Conuuclory 1-i-
cea, Law does not apply SO an 0% net of prope"Y whn builds mimproves thereon, and QTY.
whn umvads
in,, .such projects with v er,mmnods) licensed Purmom m the Cnn eacmr'.
,.i
lam exit (under Sre. .B&PC for this reason
wner Date
WORKER 'SC PENS UN D[C. RATION
1 hereby aRnn under From ID of perjury one I,I he following dedamtiInt
❑ I novo and will maintain a Cnnilicmeot Concis t0 self -insure for Wmker.Cmnpen
'aeon, as provided for by Section 37W of the Labe, Cam, fu, the perf inane, .('the
work for which,his permit is issued
1 have and will maintain Workers Compensation Inwmnce, as required by Section
37W ofthe CrIN r Code, for the p,pommne, of the work for which this permit is issued.
My Wod:ces Comlensmion Insurance carrier and Policy number are:
Corm". Policy No.:
CF,RTII'ICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(This section need nm be completed lf,he permh Is (atone hundred dollars, (S Iot)
loss)
I oyany,nm in the anymanDn-barreare oast wad Nor subject to perm' Is issued, l.hull
no, employ any person in any manner m as to hennne subject In the Workers' Cnmpcn-
smion Laws of California. Dart
Applicant
NOTICE TO APPLICAN'C If, at,,, making ,his Certificate of Exemption, you should
become subject to the Wodces Compensation pmvisinns of She Labor Cede, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'I-RuctTON LENDING AGENCY
I hereby affna that there is a u.o:uuertnn laaling ogcncy for the pedbnnanee Of
I the work for wInch ,his peroth is issued (Set. 3110], Civ. C.)
Lcuder's Name
I lenders Addreu
1 certify the, I have read this application and stale Inas he above infnmuhon is
1 roneel. I agree m comply with all city and county ordinances and state laws relating to QTY.
building construction, and hereby authorize representatives of this city m enter urym She
berve-mentioned grape ty far inspection purpose..
(We) agree It) save, Indemnify and keep hermless,he City of CUPeonno against
I'mbili,ics,judgnnns, d,Xta and exrea,v, which nnty in any way acture -Intel, said City
in con.tqucnce of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POIN'f
SOURCE RF`,jJLAT1ONS. A ^ A
SiHAlARDOUS MATERIALS DISCLOSURE
Will She opplicam or filum building occupum.aom or handle haardous mutarial
as defined by the Cupertino Municipal Cade. Chapter IS, 12, and the health unit Safe I,
Cock. Section 25532(x)?
E] yes 0 N
Will She applicant or future Wilding occupant use equipment or devices which
,,it h ob den, air coma ninaats as defined by the Bay Area Air Quality Management
District?
❑Yes 0 N
I have rend the hamNous materials onfirsmems under Chapter 6.95 of the Call -
forma Health & Safety Code. Suctions 25511.5, 25533 and 25534.1 unde'amnd Ihn, If the
building docs not currently have a tenon, that II ism, me...... day,, mai,', the cecnpnn,
ofIM1c re,incmem, which must be me, prior m issuance If CeniGeme of Oaupmwy.
.....__..-....._�._0 INN,
PLUMBING PERMIT
PERMITISSUANCE
ALTER — DRAIN & VENT— WATER hl),)
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR. ROOF, AREA. CONI(,
FIXTURUS— PER 'FRAP
GAS — EA. SYSTEM -I INC. 4 OUT LEIS
GAS — PMA. SYSTEM -OVER 4 (EA)
GREASI]INDUSTRL WASTE INI'IRCEPBIR
GREASE'I RAP
SEWER — SANITARY — STORM IA. 21X1 Ii
WATEHE;AT1;R W/VENI'IRECTR
WATER SYSfEMTREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT
MECHANICAL PERMIT
PERMITISSUANCE
AUFIR OR ADD 10 MSCI{,
AIR HANDLING UNIT (TO ](),(XX) CIM)
AIR HANDLING UNIT (OVER 10,(1X) CFM)
EXI IAUST HOOD DV/DUCT)
HEATING UNIT (TO I0(f( 0BTU)
HITATINC, UNIT (OVER It(Mbl l BTU)
VENTILATION PAN (SINGLE RESID)
BOILL'R— COST (3HP OR lip.on)PTU)
AOJUE—COMP (OVER IM,00IBTU)
IRC(lNDfINER
NEW RESIDENDALMECH. SQ. P1'.
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FELT
JAN 30 ANSI
CITY Ur uurcm I uvU
STORIES
BUILDING DIVISION FEES
YLANCIIECK THE
ENERGY FEE
GRADING FIS'
SOILS RE
PAID
D i R tip,%
TO'I'AI:
BUILDING PERMIT INTO
BUILDING ME!
BLDG IiLEQ' PLUMB Mlicll
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JOB DESCRIPTION
RESIDENTIAL
❑SETJWL TCHI:N REMODEL
ADDITION P PLUMBING Rf PIPE
❑MULTI -UNIT' ILJSTRUCTURAL
MODIFICATION
El INTERIOR [I CHIMNEY RI?PAIR
IMPROVEMENT0SWIMMING POOLS
[]LE
❑ BATH REMODEIJISFFA1R ❑fT10
❑ OTHER
PLUMBIN PER
MECI{AN L FEE
CONSTRUCT 10 X
HOUSING MITIGA IO IE
COMMERCIAL:
❑ NEW BLDGIAGUrSTON ❑DEMO1.ffION
❑TENANT ❑ Fool) SERVICE
IMPROVEMENT
❑ OTHER
PAID
Dane R"cip a
FELT
JAN 30 ANSI
CITY Ur uurcm I uvU
STORIES
BUILDING DIVISION FEES
YLANCIIECK THE
ENERGY FEE
GRADING FIS'
SOILS RE
ISSUANCE DDDAA/yTEE
BY:
LSQ.
PAID
D i R tip,%
TO'I'AI:
BUILDING ME!
FEE
SEISMIC THE
ELECTRIC F T
PLUMBIN PER
MECI{AN L FEE
CONSTRUCT 10 X
HOUSING MITIGA IO IE
PAID
Dane R"cip a
ISSUANCE DDDAA/yTEE
BY:
LSQ.