S 1175 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
1$UILDING DIVISION APPLICATIONWERMIT 1'I,UNIHING-MECHANICAL S 1175
NUILEMO PROJECT IDENITIF'ICATIUN �J
ILDING ADORES$: SANITARY NO. APPLICATION SUBMITTAL DATE
40
O N iR'S NAME: PHONE CONTRACTOR'S NAMI?: LIC NO: �`
NI —110 M
.� A CHITECT/ENGINEER: LIC NO: / f//
CONGA CT. PHONE: BUILDING PERMIT INFO
❑ COnsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECIi
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
nerals,a(Rw that I am licensed under parkin ns of chapter 9 Hammencall JOB DESCRIPTION
W qpO wnh Section 7(XXBtf Division 3 of the Business and Prefession,Ctde,md my live.' PERMIT ISSUANCE RESIDENTIAL
NW In full heart,and effect. ❑SFDWLKITCHEN REMODEL
aUV Littnse Class L10.M APPLIANCES-RBIDEN'I'[Al. ❑ADDITION PI.UMBING RE PIPE
ZW Data Contractor
�n6 p, ❑MULTI-UNIT STRUCTURAL.
ARCHTTF(CTS DECLARATION
tn PANELS MODIFlCATION
ZO�34 IunJcmmnd my Plxnx shall he used as puM1lic records UPTf1210AM1'S
❑
OZ�� INTERIOR ❑CHIMNEY RIiPAIR
(t-.~W Licensed Pmfcssi...I 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
-? OWNER-BUILDER DECLARATION
'a, 1 hereby affirm that I ma exempt from the ContractorsLicense Law for the OVER I"AMPS ATH REMOUEUREPAIR DEMOLITION
01
ipyx5,O y U following reason.(Section 7031.5,Business and Provisions Code:Any city m county SIGNS ELEC'T'RICAL )THER
u+31+•h which requires a permit to consumer,alcom
r,improve,deolish.rat repair any saucmrc ,J
�4'O� prior to its issuance,also inquires the applicant for such pewitto file a signed statement SPECIAL CIRCUIT/MISC.
d� that he is licensed pursuant m thePnwisinnsoRhO Contractor,License Law(CTupter9
CO (commencing with Section 90(0)of Division 3 of the Buslncss and Professions Code)or TEM R METER OR POLE INST COMMERCIAL:
d q tY that he is exempt thrnfram and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLXl I+y Scamm103LS by any upplicantfar a permit subjects the applicant to a civil penalty of POWER DEV ICES ❑TENANT ❑FOOD SERVICE
t marc than Ove hundred dollars($5101. IMPROVEMENT
p ❑I,as owner of the prnpcny,nr mycntployetswithwagesmthei...lareal,amatian, SWIMMING POOL ELECTRIC
will do the wnrk,and the....more d o
is not inlehdendhered for sale(Sec]041,Business ❑OTHER
W and Pra(essinns Code:The Commcmes Liceme law does not apply to an Owner of OU FLETS-SWITCHES-FIXTURES
0.3— property who builds or Initiatives thereon,and who does such wnrk himself m through
hie.wn employees,pnrvideJ that such impmvemems art not intended or offered for NEW RESIDENTIAL BLECI'R SQ FT.
sale.If,however,the Wiling.r improvement i—old withinnne yam.rc.mpleti.n,the act
SQ.II'.I10 R SISQ.FT.
r.h.0cer will have the hoNen of paving that he did no,build or improve for pun
,now i f sale.). qb g
I,as owner of the Fallacy,am exclusively contracting with licensed contractors to TOTAL av /11fiF
comuuet theprojec t(Seo.9W4,Busies
ns Imd Pn fc,,iml Code:)The Committers I.i-
se Law does not apply mannwnen+f propecs
nywhobuilJsnrimprovthercnn,anJ QTY PLUMBING PERMIT FEE C11'yVr
who contracts for such projecu withacimmismrod firepardparremind to the Cantracm �rs Vrcf
License Law. PERMIT ISSUANCE L F IOU
❑I am ezmnpl under Sec. .II&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT.DEVICE O
1 hereby affirm under penalty.(perjury one of the fnlhwing dedamtions:
Fl I have and will maintain u CeNlic:ne of Consent to self-imnre for Worker's Compact. DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONS'1'RIICTION
ration,as provided far by Section 37M of the Labor Cade,for the performance of the
work far which this pewit is Issued. FIXTURES-PER*TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3900 of the labor Code,for the peruniance.IThe wnrk for wh tell this pennit is issued. GAS-EA.SYSTEM-I INC.40I1TLET5 OCC.GROUP APN
My Worker's Compensation Insurance cancer and Policy number ore:
Carrie, Policy Ni,: GAS-EA.SYSTEM-OVI:R 4(EA,)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need ail be compla, w6is for one hundred dollars TS 100) GREASETRAP
rebels.
) 1'LANCHECK IsEF.
t nth,perform ce Ifthewo far whi�his it is issued.I shall SEWER-SANITARY-STORM EA.2(X1 FT.nut aO on in any her an a,. e t s Sj he Wrrkern'CnmFen- IiNEROY PEIi07, ,aliofornin.Um / WATER HIiA'I IiH W/V[N'I'IELECTBz Appl (TRADING Flili
yOTIJN .IL. cr making this nticate o(Eaemptinn.you should Wq'IER SYSI'F.MRREATINGSOILS F[E
F,/[' hecothe t5�kers Compensation provision,of the labor Cale,you mstiCt I„O+ fochwith�ch provisions or this pewit shall be deemed revoked. WATIiR SERVICE
QCONSTRUCTION LENDING AGENCY NEW RE.SIUIiN 'IAI.PCMB. SQ.PI'. PAID
Zliw thanhere i,acnn,wctien lending agency Tonne pcdowance of Data Receiptg
LUO thework fo.which this permit is issued(Site .1099,Civ.C.) y1'AL:
Q U Lenders Name
Lenders Address TOTAL.:
yI cecify that I have read this application and halu that the above information Ls BUILDING PF.E
fA correi l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building construction.and herehy authorize rcprawntati.cs of thiscity Instant upon the SEISMIC FEE
ah.ve-meminned pmlaffy far inspection purlwses. PERMIT ISSUANCE
1 We)agree m save,indemnify and keep hawless the City of Cattleman against ELECTRIC PIiE
liab 'ud4n, and ax n swhich mayinany way accede against said City ALTER OR ADD TO MECH. PLUMBING TEE
conseq
crucialmain this units, -
APPLIC NDSA )WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT p'O IO,1N0 CPM) MIiCHANICAL FEE
SOURC RE . IAIR HANDLING UNIT(OVER U)JXO CFM) CONSTRUCTION TA
Si fr tar ft, EXHAUST HOOD(W/DUCT) HOUSING MI'I'IGA ON FEE
RDOUS MATERIALS DISCLOSUREWillfntralluildin,oce... tort or handle hueuNous mamoal HEATING UNIT(TO 10.00 BTU)
detract by the Catarina Municipal Code,Chapter 9.12,and the Health and Safety
'We.Station 25592(.)', HEATING UNIT(OVER 1M."BTU)
❑Yes Fl No VENTILATION FAN(SING RFSID) PAID `
Re ipt p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR 1(0,(X7)BTU)
emit hmuN.us air contnnsinams ns defined by the Bay Arca Air Quality Management I TAL:
Distnct? BOILER-COMP(OVER I(O,M)BTU)
❑Yes ❑Nn
I have read the InAndnusmme6ils"Orentems under Chapter 6,95 Of the Culi- AIRCONDITIONER ISSUANCE DAT'
farmer Health&Safny Code,Sections 25505,25533 and 255W.1 understand that if the NEW RESIDENTIAL MI CH. SQ.FT.
building Jas nm currently have a conal.Nm it fifty responsibility to nrnify the Occupant
of he rcquiremems which must he and Poor to issuance of a Carinal of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY.
OFFICE