30218APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
r AR HI GINE
ADD F.SS: I
BUILDING -ELECTRICAL
PERMITNO,
BUILDING DIVISION
APPLICATIONIPERMIT
PLUMBING - MECHANICAL
0
BUILDING PERMIT INFO
BUILDING PROJECT IDENTIFICATION
❑ Cc ... Itanl Fees Paid by Applicant (Initial)
BUILDINGADDRESS:
QTY ELECTRIC PERMIT FEE
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SANITARY NO.
APPLICATION SUBMITTAL DATE
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PANELS
UP TO 200 AMPS
F� W Llaensal PmfeWnnul
J OWNER -BUILDER DECLARATION
C Q I hereby affirm than I am exempt frum the Ci m usioex License Law for the
1d O6U fallowing Person.(Sation 7031.5. Business and Professions Code: Any city.'emirty
F40 F. which requires a permit to conouram, alter, improve, demolish, m repair any stmaure
cr� .i print its Issuance, also requires the Pillions for such permit In rile a signed statement
rgW thatheislicinsedpursuann. the Provisions of the CoPmwPrx License Law (Chapter 9
LICI NO:
ADD F.SS: I
❑
f0.�'rr�,J
CO CT. PHONE:
BUILDING PERMIT INFO
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❑ Cc ... Itanl Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
1:1 EJ
QTY ELECTRIC PERMIT FEE
C=Z
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L CONTRACTOR'S DECLARATION
1 hereby aft that I am licensed once' provisions of Chapter 9 (commencing
with Sation]Dk7)nf DivisionJofthe Business and Rofessiov Code, nndm Rcenu is
y
m lull force and effect
License Class Lia#
Dam Cantmeno
- ARCHITECTS DECLARATION
1 understand my plans shell be used as public recoils
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. C1 KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
❑ INTERIOR ❑CHIMNEYREPAIR t
I.
MPROVEMENT
❑ BATH REMODFI/REPAIR ❑ DEMOLITION
❑OTHER
PERMIT ISSUANCE,
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200 AMPS
F� W Llaensal PmfeWnnul
J OWNER -BUILDER DECLARATION
C Q I hereby affirm than I am exempt frum the Ci m usioex License Law for the
1d O6U fallowing Person.(Sation 7031.5. Business and Professions Code: Any city.'emirty
F40 F. which requires a permit to conouram, alter, improve, demolish, m repair any stmaure
cr� .i print its Issuance, also requires the Pillions for such permit In rile a signed statement
rgW thatheislicinsedpursuann. the Provisions of the CoPmwPrx License Law (Chapter 9
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
S PL'CIAL CIRCUIDMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
El NEW BLDG/ADDITION ❑ DEMOLITION
TENANT FOODSERVICE
❑❑
IMPROVEMENT
❑OTHIiR
5�C) (commencing with Section 7000) of Division ufthe Business and Professions Cass)or
a p, K that he is exempt Therefrom and the basis for the alleged exemption. Any violation of
rt W Sermon 7031.5 byany upplicant it,,. permi,,mblects theapplicvnt to. civil penallyor
LLl not more than Five hundred dollars ($500),
1, as owner of the ro norm em to res with we es as their sole cons tion,
O ❑ t Fe Y Y P Y g ,ansa
y, will domewmk. anee no
istors Lic,n,a Lawdarf, no, appey.I,,v. a oviBusm, of
owner of
ad Professions Ids or The Cnmtacmr's License Lawdoesnotrk himself
3 or improves t mW who does such work hlmxvIf nr through
pommy whooye
POWER DEVICES
SWIMMING IDOL ELECTRIC
OUfLEIs-SWITCHES-IIXTURES
s:
that such i
his own employees: provided mut such impmvemems arc not intended nr .tiered 1'or
NIiW RESIDENTIAL ELECTR SQ Pi.OF
F
salc.ILh.wm'er. the budding or improvement is sold within one Year nfv,Z,letiom, the
-
SQ. PT. ROOI La
ESQ FT
owner -builder will have the burden of proving that he did not build m im,rove Tor par-
Pau of sale.).
A ,y� V
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- TOTAL:
0 I, as owner PI the property, .,it exclusively contracting with licensed cnnu ,d... m
command the project (See 70OL Business and Professions Code:) The Cnmmcmr'a I.i-
` 11WI
VUl-t fif
jry/ 1
QTY PLUMBING PERMIT FEE
nu Lawdoes not apply Pont, ownerofpm,eny, who bunds of Print thereon,and
V
wbo rontracts for such projests with a eonmaanr(s) licensed pursuant to the Cnnaaam's
PERMIT ISSUANCE
License Law.
I Pan exempt under Sec. ,B& P C for Thisre... P
ALTER -DRAIN&VENT-WATER Too
Owner Dam
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the ftllowing declnrntions7
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
Imo and will maintains CeniOcamof Commn t relf-inomefor Worker's Compcm
sarion, us provided for by Section 37M of the Luther Code, for the performance of the
STORIES
'TYPE CONSTRUCTION
FIXTURES - PER TRAP
work for which this permit is issuer.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Luton Code, for the performance of the work for which this permit is iesucnl.
My Worker's Compensation Insurance carrier and Policy number are:
GAS - EA. SYS GEM -I INC. 4 OUTLETS
OCC. GROUP
APN
Cartier. Policy N..:
GAS -EA. SYSTEM -OVER 4 (IA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
-
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COMPENSATION INSURANCE
(This section need and becomplaulifthe,armdt lsfonmchundred Aollors($100)
m les'.)
I cenifymm in theperfonnrnceMme workforwhich Theperm.
itis issued
ten emPloyany Erosion I. any man ... loss at become object to the Worker; Com n-
..Pian taws of California. Dade
Applicant
PP
GREAsKINDl15'IRL WASTE INTERCEPTOR
BUILD 0DIVISION FRES
-
GREASE TRAP
PLANCHECK 2 OLI ,
SEWER -SANITARY -STORM .20(i
EA
ENERGY FE
WATER HEATER W/VE"WAILECTR
GRADIN FE
NOTICEthis Cerdficalensof of Lathariode,y yoshou
APPLICANT. the Worker's
after Compensation
cames subject
become subject m the Workers Coons or this provisions of the meed Cede you must
forthwith comply with such provisions or permit shall be deemed revoke.).
CONSTRUCTION LENOINGACENCY
Ihor by agency fonhe Performance of
WATER SYSTF.M/IREATING
SOILS FBf
WATER SERVICE
PAID
¢ Receipt If
NEW RRSIDENTIALPLMB. SQ. FT
Is., F-'
0 U
G
which thithauhemissued(Su.3M,, Cre.
theLe wok for which This pcnniT is;swat(gee. l09],Civ.CJ -
Lender's Name
Lender's Address
I certify Dim I have read this is
that me above iws
TOTAL:
BUILDING TEE
Zcortu0lag
reemro, and withal city and cnuntyordhmnces and ntam lawsr upongPo
y and coup y o dstateins rel ang
cnmwnion, vnd hereby auth.tize rcprtumvuver of This city do enter upon the
QTY. MECHANICAL PERMIT FEEZbuilding
SCISMICI �F,
above-mentioned property for inspection putpous. r
agree msive, indemnify and keep harmless 0¢CityofCupcoin. against
PERMIT ISSUANCE(We)
ELECTRI :IEEliabilities,judgmemts
or
suand expenses which may in any way accme againsissid City
in con qunax oft ung oflhis permit.
ALTERORADDIDMECH.
PLUMBI FEC
AIR HANDLING UNIT (TO 10.000 CFM)
APPI ANT U E 'ANDS AND WILL COMPLY WITH ALL NON -POINT
SOU CF, REGU T S.
MF. CHANICALF
AIR HANDLING UNIT (OVER 10,00) CFM)
CONSTRUCi1ONTAX
igp c Cnn cmr [).to
IAZARDOUS MATERIALS DISCLOSURE.
Ill
EXHAUST HOLD(WMUCD
HOUSING MITIGATION FF,
II BATING UNIT 00 1Pat BE
Will the u„licant or future bulldlng oefupant marc nr handle hawrduuw mmerial
M by me Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(nl?
HEATING UNIT (OVER 100,000 BTU)
•
[_1 Yaw ❑No
Will meuse e. Ail Qu or devises which
is oit comms or furore building by the
emit ic'? us yr cnntaminems as defined by the Bay Area Air Quality Managcmend
Diraicd?
PAID
Dade Receipt If
VENTI LATION FAN (SINGLE RE SID)
BOILER -COMP IJHP OR I1q.000 BTU)
TOTAL:
BOILER-COMP(OVER I(I(1,01X1 BTU) '
❑Nn
AIR CONDITIONER
ead the haradous nate0als requirements under Chapter 6.95 of the Call.
Safety Cede, Sation. 25505, 25573 and 2550 I understand mat if me
ot currently have a tenant, mm it is my responsibility m notify the occupant
L
ISSUANCE DATE:
NEW RESIDENTIAL MECH. SQ. FT.
ents which muonmd
ISSUED BY: _.
agent - ])age
TO'rAl:
OFFICE