30410APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
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WLDING ADDRESS:
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SANITARY NO.
APPLICATION SUBMITTAL DAT[
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iRCH116CUMNIGINEEM LrC No:
COMIN IOR'S NAME: IJC NO :
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CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ t�
LICENSED CONTRACTOR'S DECLARATIONQTY.
1 hereby affirm that 1 am licensed under previsions of Chapter 9 (cotmnencing
with Section 7000) of Division 34 he Bmrwclmd Professions Colaand try ]fee. is
in full [..,.ad effect.
License Cbtss LIC.k
D Contractor
ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL El KITCHEN RFMODEL
❑ADDITION [I PLUMBING REPIPE
❑MULTLUNIT []STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR ❑DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES— RESIDENTIAL
As shot) iised.ECLARATION
lundersund my plans shall he usul es public records
PANELS
UP1'0 2M AMPS
Licensed l'rofessionel
DECLARATION Contractor's
Oat lam exempt
I hereby affirm that I am exempt from the Contractor's Cade: Any I Ise for the
following ices reason. Section 7onstru Business and Professionsh.orAny city or county
which requires a permit m construct, aper, improve, demnlivh, or repair any structure
print to its issuance, also rcyuiree the applicant far such pennilmlileusigncJ smrement
that he is licensed pasuanuo the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70siol: Division 3 oft he Business and Prowsslons Cache) in
that he is exempt therefrom imd the hu.is for tendered! e.aemption, Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more then five hundred dollars(531X1).
I,azowner of the y p y g
❑ pmpeny, arm em to acs with woe csss Neir sole cam nsetion,
will dnthework, end Nemosenre is ant mandedim.fered far sate Sec. 7My Business
and Pmfessions Cade: The Contractors License Law does not apply m as owner of
Empathy who builds or improves thereon, and who does such work himself or Enough
his awn employees, provided that such Improvements arc not intended or offered for
sale. If. however, the building or improvement is sold within one yearo(completion, the
awn
owner-builder will have the burden of proving that he did not build or improve for par-
pose of sole.). -
I, as owner of the property, ren eseltisively contracting with licensed ennwetors to
vrsauct the maject (Sec. 7044, nosiness and Professions Cade:) The Contractor's U-
cense Law does not apply to an owner of railway who builds or improves thereon,and
who contracts for such prefects with a contractors) licensed pursuant o the Contractors
License Law.
I am exempt under Sce. , B & PC for this reason
201-1000AMPS
OVER U700AMPS �
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
_
TBMP. M E'rER OR POLE I NST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
BOTHER
POWER DEVICES
SWIMMING
SWIMMING POOL ELECTRIC
OUfLITFS—SWITCHES—FIXTURES
NEW W RESIDENTIAL ELECTR SQ FT.
5 _ AHI
V �O
'ta v
/ Uh
4.11 1 JJ 4(J
'
S/SQ. PI'.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTUR— DRAIN & VENT— WATER TA)
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pepury one of the following declarations:
❑Ihave.ndwillmainmin. Cenilicmeof Consenitoself-insumfor Worker's Compen-
safud, us provided for by Section 3700 of the Labor Code, far the perfommnce of the
work for which this permit is issued.
Fl I have and will mutation Worker's Compensation Insurance, as required by Section
3700 ofthe labor Code, for the permommice ofthe work for which this permit is issue).
My Workers Compensation lnsumnew carrier and Policy number are:
Carrier: Policy No:
CERTIFICATE OF EXFMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section nerd and be completed ifthe permit is for one hundred dollars IS [ad)
or less.)
this permit isissued, rs,Co.,.-shallSEWER—SANITARY—STORM
Toy any that int he performance of the becameork for subject
mil employ y person in any marineis to become-ubjeco to the Wnrkers'Copem
ration L. C ])at H��
Aprliuum_ r —
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF AREA, GOND.
STORIES
TYPE CONSTRUCTION
FIXTURES — PER TRAP
GAS— EA. SYSTEM-] INC. 4 OUT
OCC GROUP
APN
_L
GAS—EA. SYSTEM -OVER 4 (EA)
GRCASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION HIS
GREASETRAP
PLANCHECK FEE
FA. 200 FT.
ENERGY FEE
WATI3N 1113ATER WNENT/ELECfR
GRADING FEE
'J f 1'
NOTICE. Tje A ANT: ifl.s Co i v akmg this Gonion of FLabortinn, you should
become subject to the Worker's Compenretion provisions of the Labor Code, you most
forhwim comply with such previsions or this permit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Net them is a construction lending agency for performance of
the work for which this remed is issued (Sec. 3097, Ci, C.)
Lender's Name
WA1 R SYSTEMITREATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIALPLMB. SQ. FT
Date Receipt#
TOl'AL.:
Lcmer's Address -
1 cetify that 1 have rend this application and state, that the above information is
correct. I agree to comply with all city and county ordinances and stow laws relining to
building construction, and hereby authorize representatives of this city to enter upon the
aMsve-mentioned property far inspection purposes.
(We) agree m save, indemnify and keep harmless Ne City of Cupenino.gains
liabilitiesjudgments.casts and expenses which may irony way..e.,utim said City
in'cansequence of the Granting of this permic
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
BUILDING TLE
I
QTY. MECHANICAL PERMIT FEE
SEES MIC FEE
PERMIT ISSUANCE
ECTRIG FEE
PLUMBING FEE
ALTER OR ADDTO MECH.
AIR HANDLING UNIT(TO 10,0110 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCIONTAX
Signature of Applicaut/Comrucmr Date
HAZARDOUS MATERIALS DISCLOSURE
WdIdeapplicanmr fuure buildingacsapaat overt handle hmmdom material
as defined by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section M5320)?
❑Yes Fl
Will the air emant or momems aure building occupby
nt Bay Arco ipmenlor lity evices whichManagement
emit hmavdous air contaminants as defined by Ne Bay Area Air Qmliry Management
District?
❑Yes FUN.
1 have resume hazuNnus mammals reyuircments under Chapter 6.95 of the Cali
firma health & Safety Cole, Sections 25505, 25533 and 25534. 1 undermued that if the
huilding does not cumendy have a tenon(, that it is my responsibility to notify t1®¢cupom
of the requirements which must he met prior m issuance of . Certificate of f3ccupancy.
EXHAUST HOOD(WMUCT)
HOUSING MITIGATION FEE
-
HEATING UNIT (TO UNE." BTU)
HP.ATENG UNIT (OVER 100,0011 BTU)
PAID
VF.NTILATIONFAN ISINGLE RESIDE
Date Receipt#
BOILER— COMP DEEP OR 100.000 BTU)
TOTAL.
BOILER — COMP (OVER 100,1100 BTU)
AIR CONDI'T'IONER
ISSUANCE DATE
ISSUED BY:
N13W RESIUBNIIAL MECH. SQ. Fp
Owner or anduriud agent Date
TOTAL:
OFFICE