00020006APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1.'i nv BUILDING - ELECTRICAL
BUILDING DIVISION - APPLICATIONIPERMIT
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm Not I am licensed under previsions of Chapter 9 (commencing
MWz with Section 7Hl0)of Dlvidou3 ofthe Buaine,s and Professions Code, andmy license is
E+� in full force and effect. '
UU License Clu,s Lic,#
anZ W Date cConuanr
ARCHITECT'S DECLARATION
O Z -4 1 understand my plans shall be used as public mand,
IM
F.4 E' al Licensed Professional
•y' 2, OWNER -BUILDER DECLARATION
4' C4C1 1 hereby affnn that I am exempt from the Conran r, License Law for the
0,U fallowing reason. (Section 7031.5, Badness and Professions Code: Any city or county
F �,O y which requires a permit m construct, alter, improve, demolish, or repair any structure
prior to its Issuance, also requires the applicant foe such permit to file signed statement
that he is licensed pursuant to the provisions ofthe Companies License Law (CM1ap,er9
-00 (commencing with Section 7000) of Division 3 of the Business and Profession& Code) or
dy a Nat he is apmm I Iherofmm and the Iasis for the alleged exemption. Any violation of
bEIN Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
W.H. i+ not more than five hundred dol lar, ($500).
a01, as owner of the pmpeny, or my employees with wages as their sale compensmmor
will do the work, and Nc swewre is no, intended oroffered fief ,ale (Sec. 9044, Business
and Professions Come: The Contractor's License Law does not apply to an owner of
., property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner-lumider will have the burden of proving that he did -not build or improve for I'm-
poseo ale.).
m owner of the propurty, am exclusively contracting with licensed wnlrnctmr m
construct the project (Sec. 7144. Business and Professions CedeQ The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and QTY
who conthoU for such projects with a eom creak) licensed prompt to the Contractor
License Law.
El 1 em exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dedaadmsz
D I have and will maintain a Certificate of Consenno self -insure for Worker's Compen-
smion. as provided for by Section 3900 of the Labor Code, for the performance of the
work for which this permit m issued
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3900 of the Labor Code, for (he performance of the work for which Thi -s permit is issued.
My Wofker's Card, orm Insurance carrier and Policy number arc:
Carrier Policy No.:
CERTIFICATE. OF EXEMPTION FROM WORKERS'.
' COMPENSATION INSURANCE
(Tlds,cithm need not be emoplmed ifthe permit is Inure hundred dollars ($100)
or lass.)
1 certify that n the any manner
of sto bac m which Nis tepermitIs issued. shill
not employ any person in any meaner so as m become subject to We Werkus' Compen-
OC)cableant - CaliPomiv. Date
O Applicata t -
NOTICE TO APPLICANT. If, .fiat tanking this Certificate of Bscansion, you should
1'^ rNr
become s comp y the Worker's Compensation (it this provisions of the Lobar Code, you must
Forthwith comply with such provisions ur this permit shall be doomed revoked
Q
U O CONSTRUCTION LENDINGAGENCY -
I hereby alBnn that there is a ed iSoc. 30 lending agency for the performance of
{IceF he work Larches far which this pumit is ismed (Sec JOY], Cis. C.)
p U Lender's Name .
L1a LendersAddes,
r
I -
certify that I have read this application and state that Na state laws
dilating is
i..t Val amus. I agree m comply with all city and roomy ordinances and state laws relining m Q'py,
U z huilding amswctfon, and hcrehy authorize mpmeonmtivee of this city roenter upon the
.hove -mentioned property for inspection pm Ewa,,.
(We) agree to save, indemnify and keep harmlexs the City of Cupanino against
Ilabilitics,judgments, costs and expenses which may in any way accord against said City
In consequence of the gnmting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or More building occupant Brom nr hand], h tarinwns untanal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 21532(d?
EJ Yes ❑No
Will the applicant or (alum Im Hill iig occupant use equipment or devices which
'mit hazardous air contaminants as defined by the Bay Area Air Quality Maougement
District'!
[-1 yes No
I have and the htdardou materials requirements under Chapter 695 of the Coll -
Same Health & Safety Gale, Sections 25505, 25533 and 25534.1 understand that If the
building does not currently have a tenant. that it is my responsibility m notify the occupant
of the requirements which must be met priorto issuance of a Certificate of Occupancy.
ELECTRIC PERMUF FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
TEMP. ME'T'ER OR POLE INST ,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWIFCHES- FIXTURES
NEW RESIDENTIAL ELECTR-• 'SOIT
ALTER- BRAIN &VENT R(EA)
BACK FLOW PROTECT. DEV IC .
DRAINS -FLOOR POOP, AREA, CO
FIXTURES - PER TRAP
GAS- EA. SYSTEM- I INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASE 'I'RAP
SEWER - SANITARY- STORM EA. 200 FI',
WATER IWA'i'ER W/VENT/ELECTR
WATER SYSI EM HEATING
WATER SERVICE
NEW RESIIIEN'IIALPLMH, SQ. FT.
TOTAL:
PER
PERMIT ISSUANCE.
AL'T'ER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD(WMUCU
HEATING UNIT (TO I llq(lll0 BTU)
I [EATING UNIT (OVER 100,000 BTU)
VHNTILATION FAN (SINGLE RES Go
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDEN"TIAL MF.CI I. SQ, Ff.
TOTAL'.
OFFICE
FEF
NIC CONTROL
JOB DENCRIP'11ON ,
RESIDENTIAL:
#
❑SFDWI.
❑ KITCHEN REMODEL
El ADDITION
❑PLUMBING RE -PIPE
[I MULTI -UNIT
❑ STRUCTURAL
-BUILUINO PERMIT INFO
El INTERIOR
BLDG
E,L-E-CT'/
PLUMB
M,ECH
L4
❑
I!QCH
NIC CONTROL
JOB DENCRIP'11ON ,
RESIDENTIAL:
❑SFDWI.
❑ KITCHEN REMODEL
El ADDITION
❑PLUMBING RE -PIPE
[I MULTI -UNIT
❑ STRUCTURAL
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑BA'1'HREMODEUREPAIR EIDEMOLITION
NFvfv��LDCIAD ION ❑ DEMOLITION
❑ T'NAN"!'� -1 FOOD SERVICE
IMP NT
❑ OTHER
SQ. IeU FLOOR AREA
0 900
PLANCHECK FEE
IiN F.I2GY WE
GRADING FEE
SOILS FEE
SEISMIC FEE
ELECTRIC FEE
MF.CHANICAI. FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
$/SQ. IT.
PAID
Dine Rccipt #
e
'TOTAL. 4 (all - 111
ISSUANCE DATE
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