99100144APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELF.C'TR
BUILDING DIVISION APPIACATION/PERMIT PLUMBING"MEctln''
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
1 hereM1y u(frm that I am licensed under provisions of Chapter 9 (commencing
Oc, 22 with Section 7IXN1)mfDivision3of the Business and Professions/Code, anZ/ dmylicennei
U U Lime me aod 'at.3 Lic. N3 t0 (CEJ
�ZJ W Date' d�ocmr
' _ V,ECTS DECLAN ION —
izi Z I understand my plans shall M used as Public records
WLicensed Prafesaio al
OWNER-BUILDER DECLARATION
I hereby if,. shut I me exempt from the Contractor's License Law, for the
1 � U following reason. (Section 7031.5. Business and Professions Code: Any city or county
C which requires a permit to construct. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant far such Penn to file a signed statement
N that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
QC(commencing with Section?")nf Division 3 of Ne Business and Professions Code)
cy� that he is exempt therefrom and the basis for this alleged exemption. Any violation of
Section 7031.5 by any applicant for. pemtit subjects the applicant to a civil penalty of
Zon not mom Nan rive hundred dollars ($500).
NO(]1, as sooner M the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
J end PmfrWina Code: The Contractor's License Law does not apply to ua owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided thin such improvements ore not intended or offered for
sato. if, however, the building or improvement is sold within one year of completion, the
owneoM1uilder will have the burden of proving that he did not build or improve for pur-
(').
ia owner of the property, oto exclusively contracting with licensed contractors fm
construct me project (Sec 9044, Business and Professions Ca1ep'Hm Contmetorls Li.
cense law does not apply to an owner of property who huilds or improves theremn, and QTY.
who contracts for such pmjocn with a mouracmr(s) licensed Common to the Contractors
License Law.
1 am exempt under Sec. . B & P C for this reason
.Owner, Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following doelamticns
❑ I have and will maintain a Certificate of Consent to xelFihemefor Worker's Compen-
safion, as provided for by Section 370C) of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker, Compensation Insurance, m required by Section
3700oflhe Labor Cade, for the pcommunccof me work for which this pemsit's issued
morter and Policy
C Work . CyeRnsatICATE OF EXEMPTION Policy
FROM� NJf�NJf�j'R�� O� ��
COMPENSATION INSURANCE /"I O• --k
(Thi, section need not Is, completed if the pemtit is name hundred dollars (Sills)
mlFx7
I certify that in the performance.fthe work far which this hermit is issued, Ialull
not employ any person in any manner an as to became subject to the Workers' Coroner-
maim
omlen-
sa i m laws of California. Date -
OO Applicant )
NOTICE TO APPLICANT. If, ager making this Ceniricme of Exemption, you should
h' became subject m the Workers Compewttion provisions of the Labor Cal, you must
furbwith comply with such provisions or this permit shall be deemed revocked.
ZD z 6,
CONSTRUCTION LENDING AGENCY
LiQ I for
rwhich nusthat
permereis..so(S (Sm. 300,
fnnhe Performance of
W me wmrkfor which owls permit is issued (Sue. 3fW7, Ci, C.)
0 U Lender, Name
DJ Lenders Address
Pro I certify that I have read this application and state that the above information Is
r y comet. l agree to comply with all city and county ordinances and sure laws relating to QTY
V Z building construction, and hereby authmiurepreconsives of this city to enter upon are
shove -mentioned pmpeny for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cuperinn against
limilities,judgmcnts, costs and expenses which may in any way same against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building excupant store or handle Iwzandous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 255326d?
C] Yes T-1 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air commutations as defined by the Bay Arta Air Quality Management
District?
❑Ye, ❑No
I have read the bornrdous oubmi I, regm smarts under amen fi 95 of the Cali-
fomia Health & Safety Code. Sections 25505, 25533 it 25534. 1 understand that if the
ELECTRIC PERMCT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02MAMPS
OVER TBW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -TOO
NEW RESIDENTIAL ELECTR
SQ PT.
6 -2 %- �1
J
BLDG ELECT
❑ ❑
FLU mn / me1n
6^!, ❑
FEB
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT I] SWIMMING POOLS
❑ BATH REMODEUREPAIR [I DEMOLITION
❑OTHER
�I CIALOMMQ�yE IA g:
❑NEWBLDG/ADDGION
❑TENANT
IMPROVEMENT
❑ OTHER
FMOLI
(:)FOODSERVICE
TOTAL:
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA. COND,
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFANDUSTRI. WASTE INTERCEPTOR
GRPASETRAP
SEWER - SANITARY - STORM EA. 200 Fr.
WATER HEATER WNENT/ELECTR
WATER SYSTEMRREATING
WATER SERVICE
NEW RESIDENTIAL PWB. SQ. FT.
MECHANICAL PERMIT I FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR II ANDI.ING UNIT (TO IRIXN) CPM)
AIR HANDLING UNIT (OVER 14000 CPM)
ID(HAUST HOOD (W/DUCT)
HEATING UNIT (TO Ift" BTU)
HEATING UNIT (OVER ]PEACE BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER - COMP(OVER I NCOTO BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. IT.
OFFICE
TOTAL:
PIANCHECK FEE
ENERGY FEE
GRADING FEF,
SOUS FEE
PAID
Data Receipt g
FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID Date Receipt ll I,
t
iv, 2