00010038FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'
CONTACT: PHONE:
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❑ Consultant Fees Paid by Applicant (Initial)
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I hcrchy dftrm that I ion hccnucd nndcr prrvWm, of Chapter 9 (cnnunencing
with Section7(danof DivisionJof the BUSlness and Pmfessiona Code. and my license is
in full force t.
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D KITCHEN REMODEL
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ARCHITECT'S /—
DECLARATION
1 nndee and my plane shall be used as public record,
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5. Business Ind Professiom Code: Any city or county
which require.. a permit to aonpmcl, slier, improve, demnli.eq or repair any swebtrc
prior to its issuance, also requires the applicant for Such Eermino file a signed shometn
that hcls licensed pursuanuothe pmvisiouaofWC Gmtracmr'a Lice Law(Chapmr9
MOOIFICNHON
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
000
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(commencing with Section 9XX)) of Division 3 ofthe Business and Professions Cl,)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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Section 9031 5 by any applicant for jec mil nuhjco, the npplhnm to a civil Pcorhy of
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not mare than five hundred dollars ($500).
Dl, as nwncrmf nc� Prnpeny, or mycmpinyecs with wages as their sole compensation,
and erty who Code: The Ceemenrs License Law ace. not apply m if owner of
andP essink, andlhe he Conscone nLicensa awdocsrraale(Sec. to an owner
property who hails, or improves thereon, and who does such work himself or through
his own employees provided that such er,00rrvemcros ti um imm�ticJ or povion fm
safe. ILhowever,thehuilding orimprovement is sold noneyearofcompletion,the
COMMERCIAll
DNEWBLDG /ADDITION
owner1 builder will have the harden of proving that he did not build or imprnvc for pur-
did
poso nl teat.).
El ENANT
CFOODSERVICE
D I, as owner mthe prupeny, non i.chtlivel, conwchng with licensed contractors at
consumer the project (Sec. 9(114, Business tied Pmfe „inns Cnda:) The Cnntnacmds i,i-
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cause
nseLawdoes not apply to am owner of pmpeny whn huildxnr improves thnavm, and
contracts for such prowls with a t onvaeump) licensed pursuant to the Contractors
License Law.
D lam exempt under Sec. ,B& P C for like, ..n
color Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dectmanm:
D I have and wit l main lion Cerlficme of Consent mach -insure for Workers Cnmpem
cation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued,
❑ 1 hive anti will maintain Workers Compenaulion Insurance, as required by Section
3100ofthe Lahr ede,'orthepMo ante of the work for which this permit is issued.
My Wnrkcr' .Insure solrand Policy. b��r/�art ,,0
CorticY. policy Nn.: fCr-�� 6,00
CE TIIICATE OF EXEMPTION PROM WORKERS' O�fI
CDMPENSAl]ON INSURANCE o
Thi not need not be mmplcied f1hepuranit is for unchurchd dollars SIM)
or less.)
1 atr i a y that in the lufmuaa,coflheworit for which this Perin, issued, Ish dl
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out employ any person in any —an, In as to become subject m the Wurken' Compem
,mire Laws of Califomia, Dam
Applicant
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NOTICE'TO APPLICANT: If, after making this Certificate of Exemption, you she
hecnme smicar to the Worker's CmEturation provisions of the Labor Code, you most
forthwith comply with such provici oat. nr this permit Oeall be deemed revoked.
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COPPO RUCTION LENDING AGENCY
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Ithemhy afftrnn tKai here is a cmatruninn lead; ng agency fin, he perfmmiance of
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the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Namm
Lender's Addms
I certify that I have read this application and scale that the above information is
c rra4.1 ale- ill amply with all city and county n fiance, and .,lute laws miming In
contraction. and hereby amhodze representatives ofthis city to enter upon the
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above- mentioned property for inspection purynses.
(We) agree to save, indemnify and keep harmless the Ciry of CuPertlnc again”
habilities,judgends, costs and expenses which may in any way same against said City
in ..sequence of the granting of this permit.
APPLICANT UNDFItSTANDS AND WILL COMPLY WITH ALI. NON - POINT'
SOURCE REGULATIONS.
Signature of Applica r /Contmcmr Dam
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building occupant pore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hcahh and Safety
Cale, Secrie 0 25532w)!
' DYes Fl No
Will the applicant or furore building overpaid use equipment nr devices which
Suit harardous it contantiwnm. defined by the It, Area Air Quality Management
District?
Dvea F-) No
I have read the hnrnlnue mDCriuls requirements under Chapter 6,95 rflho Cali
fond. Health & Safety Cale, Sections 25505, 25533 and M511. I understand That if the
building does not c mently have a tenant, that it is my rcnponsibility to notify the tecupant
of Ilia re,mmun cot, which mom he it ..jar m issuance of a Cori "'Ole of Oe,,ofor y.
Owner nr amhnnzed .gear Date
PERMIT ISSUANCE
APPLIANCLS - RESIDENTIAL
PAN12LS
UP FO 200 AMPS
OVER 1000AMPS
SIGNS ELECTRICAI,
SPECIAL CIRCUFUMISC.
TEMP. METER OR NILE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES - FIXTURES
NEW RES I DENTIA 1, ELHC'I'It
PERMIT ISSUANCE
Aumll - DRAIN & VENIT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA. CFIND,
FIXTURES- PER "TRAP
GAS - EA. SYSTEM -1 INC. A OUTLETS
GAS -EA. SYSTEM -OVER 4 (EA)
GRHASEANDUS'I'RL WASTE IM'IiRCEPTOR
GRIiASE TRAP
SEWER - SANITARY - S'IORM EA. 200 FK
WNI'1iR HEATER WNENVIiLECTR
WATER SYSTEWIREAMNG
WA'T'ER SERVICE
NEW BESIDIiNT1Al. PLMII. SQ, FT
MHCHANICALPERMrr
ALTER OR ADD lO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,N)B CFM)
EX14AUST HOOD (WIDUCT)
HEA'T'ING UNIT (TO 100.(0() BTU)
IIEATING UNIT' (OVFR 100,000 It 0)
VENTI TAFION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100.000 B'ED
BOILER -COMP OVER IIX)I H'1' )
AIR CONEN I IONER
NEW RESIDENTIAL MECI I. SQ. FT.
OFFICE
FEE
; BUILDING PERMIT INFO
I BLDG ELECT PLUMB MECH
11 ❑ 1:1 ❑
.IOB DESCRIPTION,
BFSIDENTIAL,
C SFDWI,
D KITCHEN REMODEL
❑ADDITION
DPLUMBINGRE -PIPE:
❑MULTI -UNIT
OSTRUCTURAL
MOOIFICNHON
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
E:1 SWIMMING POOLS
C BATH REMODEUREPAIR ❑DEMOLITIO'
C OTHER
COMMERCIAll
DNEWBLDG /ADDITION
CIDEMOLII'ION
El ENANT
CFOODSERVICE
IMPROVEMENT
COFFER
SR FT. FLOOR AREA
STORIES
)WILDING DIVISION IT is
PI.ANCHI!CK FEE
ENERGY FEE
GRADING FEE
SOILS ME
PAID
Date Receipt#
BUILDING FEE
FEE
SEISMIC FFE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL ITHE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID Dale Iteccipl#
11 'ITTAL: /fir I1
ISSUANCE DATIi