S 13031PPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - BLEcrRICAL
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -MECHANICAL
BUILDING Pini tD6MriPICA
BUILDING ADDRESS:
IN'\ LI nv C _ _.__ AVG
NAME:
C-11171
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
WOO with Section 9000) of Division 3 of the Ruslness and Prefer ions Code, and my license is
a1_ in full force and effee429
6 .33 4
d U$ U Li,en
NZ ad Date G�mracto w�
q0.q A i HITBCC'S DECLARATION
�,,IZ l understand my pIkaw shall lc used as public records
0 ill-
F,'3lr�W Licensed P ...local
OWNER-RUH.DF.R DECLARATION
1 hereby affirm that 1 1 exempt from the C"Ifink o e: Ad, Law for the
3 W U following reason (Section 7031S, Business and Professions Cod,: Any r$y or county
which requires u pennrt m cungru 1, area, improve, demolish, or repair any eI em
1"'190 prinrtnunissmnw,almrequirntheapplicantfrwchpnniltmfileasignedsavmmm�t
that he is licensed pursuant to the provlstom5 of the Gmtracte;"s License Law (Chapter 9
macro mnei ng with Section 9000) of Divi sine 3 of the Basi nese and Professions Code)or
dry� o a the he is exempt Iherefmm until he basis for the alleged exemption. Any vioh;llon of
W 0 Scene, 90315 by any optional for a permit cal iia, the applic:mt to a civil penally of
ma e than five hundred dollars V500).
C ❑ 1 �ae owner 01 toe prnpeH , or mY employees with wages as Eric solo compensation.
000000000000 p.t� will dothework, and theslructure is not amended oreffered forsnlclSee. 7044, Business
and Pnmansmal Code: The Contractors License Low does nm apply to an owner of
d property who builds or improves thereon. and who don such work himself or through
his owa cmi provided that such improvements arc not intended or ollimd for
sale. it however, the building a improvement is sold within one year of completion, the
nrootmIder will have the burden of proving that he did not build or improve for pur-
pe5e of s:nleJ.
01 owner fthe property, hu ly contractingw01' I contractorsno
conduct d iaujod(S 7044 Business IP finso sCad')TM1 Contractor 'Li
Li-
cense L 1 n apply r f property ho builds or unprovesahs d QTY.
who contracts for such projects it out t OI'vmodpemend to the C m a
License L
I am exempt under Sec. . B & P C for this me...
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one or the following declarations:
❑ I have and will ac imnin a Ford Franc of Consent to self -in rue For Worker's Compen-
action, ns provided for by Section 3700 of the Labor Cade, for the perfnmor,c of the
week for which this Permit is i .... d.
❑ 1 have and will number Workers Compensation Insurance, as acquired by Section
3700 of the Labor Code, for the performance of the work for whichthisperiod is Issued.
My Works& Ja%,`s�ratiopinA earn rPand
Policy
a L
CURIO. i1d• i� y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed tribe permit is Tomos hundacaldellars ($ I W)
1eenify thein, In any onconsa of, tworkforwh'mh this Permit icer,'C lshell
air, employ Low any person In any mamnu xo ns m homes snhj,e to the WorkeM Cnmpen-
O%. smion Laws of CullPornia. Dale
Q Applicant
NOTICE TO APPLICANT: If, afar making this Creditorsof Exemption, you should
(~ hecnmo snorer m the Workers Cona,movien provisions of the Labor Codd. yon must
forthwith comply with such provisions or this permit shall be deemed rcvokW.
Z CONSTRUCTION LENDING AGENCY
1lIn, w affirm the (here 6 u ed (See i30 lending agency for aha prslormunceof
' w � me wnn<ror which tea permit is Toone fsee.3om, cis. cI
O U Lenders Name
U Lender's Address
as 1 erdify Thal Ihave rwJ chis npplirvlion and elute tbm Wo above infennelion is
h correct. 1 agree to comply with all city and county ordinances and state laws relating to QTY
V . building construction. anti hereby authorize representatives of this city to enter upon the
above-mentioned property for Inspection pillears.
(We) agree m save, indemnify and keep harmless the City of Cupcnino against
babiliries,judgmcnms, costs and expenses which may in any way awme against said City
in consequence or the granting of this permit.
APPLICANT' UNDERSTANDS ANDaWILL COALY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicam or future building orcupanl store nrhandle hazerdons cowered
as deMul by the Capuchin, Municipal Code, Chapter 9.12, and tire Health and Safely
Cole, Section 25532(a)9
p Ycs
E] No
•Will mho apTlieum or future building perm nt use equlpmenl or devices which
-nfl huzvrdous air cnlnaminanls as defined by the Bay Area Air Quality Manderneal
District'
ro
El Ye., E] No
1 have reed the hvoodons maerlul, espiremans under Chapter o 9 or the Cali
fomin Health & Shelly Code, Section, TEE, 25533 and 25534. 1 understand that if its
bit i lding does net much [y have atenant, that it is my responsibility Ton ti fy (he (northern
of the requirements which must he mel prior to issuance of a Certificate of Ocerponcy.
ELECTRIC PERMIT FEE
PERNH IISSUANCE
APPLIANCES - RESIDENT [A],
PANELS
UP1'0200 AMPS
201-1000 AMPS /
SIGNS ELECTRICAL
SPECIAL CIRCUIT MISC,
'TEMP. METER OR POLE INS' I'.
POWER DEVICHS
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
NEW RESIDENT Al. F.LECTR SQ FII
PLUMBING PERMIT
PERMITISSUANCF.
ALTER -DRAIN & VENT -WATER (BA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
pix 'FIBER -PER TRAP
GAS - EA. SYS '1'Plot- 1 INC. 4 OUTLETS
GAS - EA. SYSTEMOVER4 (EA)
GREASUINDIISTRL WASTE INTERCEP'TOIt
GRFASETRAP
SEW ER -SANITARY - S'IORM EA. 200 FT.
WATER DEATHS W/VEN'I/ELECTR
WATER SYSTEM(FREATING
WATER SERVICE
N HW RESIDENTIAL PLMB. SQ. IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD 10 MECH.
AIR HANDLING UNIT (TO FLUX) CPM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD (W/DUCT)
HEM ING UNIT (TO 100,100 BTU)
HEATING UNIT (OVER 100,000 RTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COMP (3HPOR 100,000 B1
BOILER -COMP (OVER I WINO B'I'U)
AIR CONDIT TONER
NF.WRESIDENTIALMVCH. SQ, Cr
"'Sit" 1303
NITARY NO. APPLICATION SGBMIITAL
Z�.
NIC CONTRl1L#
6UILDING PERMIT INFO
S�L-AG� EL17C.P PLUMB MECH
/
1 ❑ ❑ ❑
' JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL.
[]ADDITION
E:1 PLUMBING RE -PIPIT
❑MUI:H-UNIT
El STRUCTURAL
-
MODIFICATION
❑INTERIORIM'
IMPROVEMENT
SWIMMINGMING POOLS S
❑ BATH REM( DEURIiPA1R
DEMOLITION
❑ OTHER
❑ DEM01.1'I'ION
❑ FOOD SERVICE
$/SQ. IT.
FEE FEB 24 ANSI
CITY of 1rUf Col MVV
,, y S BUILDINODNiSIO_M_F_F_ES
PLANCHCCK FEE LL
ENERGY FEE
GRAVING FEE
SOILS PED
PAID
TOTAL.
BUILDING FNI
FT.E SEISMIC FEE
F,I.F.CfRIC FEE
MECHANICAL. FFE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Recedpr #
I'O'1"AL:
I ISSUED BY
OFFICE
y