30304APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING
-ELECTRICAL PERMIT NO 30304
BUILDING DIVISION APPLICATION/PERMIT PLUNKING -MECHANICAL' '
I b ( ❑ Consultant Pees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I of
licensed under previsions of Chapter 9 (commencing
to Section 7OBD) of Division 3 of the Business and Professions Cade, and my Reenacts
full force and'effecl.---. n n a 11 — I
I understand my plans shall be used as public records
C7
a h 1 - OWNER -BUILDER DECLARATION
i PC I hereby of can that am exempt from the Contractor's License Law for the
a S E. following reason. (Section 7031.5, Business and Professions Code: Any city or county
ILO which requires a permit to consumer, alter, improve, demolish, or repair any stmamre
ar
prior it issuance, also requires the applicant for such permit m file a signed statement
?J tai Nut he is liceneseB pursuant to the previsions of the Contractors License Law (Chapter 9
�a p0 (commencing with Section 7001 of Division 3 ofthe Business and Professions Cady) or
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
W m m Section ]o L5 by arty applio nt f r a pal t subbas the applioam w a civil penalty of '
not more than five hundred dollars ($50!1).
O ❑ Lo the work. the Forestry,
m dy,mmye intended
with wages as lale(See. 7compensation,, Bussss
w01 dr fie work, and the he Concis not intended or Law
do for sale(See.t 044, Business
�,3 and Professions Cade: The improve,
doe License law dces not apply m an owner. h
property who builds or improves Hereon, and who dces such weak
te himself or through
his employees, building
that such improvements are not intended or offered for
cowne If,however, will
building or improvement sold within one year of completion, the
t eo builder will Rave the burden of proving that lm did not build or improve for put,
Fund Of salad.
- ❑has owner of the property, am exclusively contracting with licensed contractors m
verceconstact theproject(Sec.oan Business and rty who oaeds or i TTevesthecmrs nd
c se Law does not applytoto owner of properly who builds rs improves thereon, and Q7g
who contracts for such projects with a femNctor(s) licensed pursuant to the Contractors
License Law. '
C 1 am 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 declarations:
C [have and will maintain a Certificate of Consent to self -insure for WorkeraCampen-
sation, as provided for by Section 37W of the labor Code, fort the performance of the
work for which this permit Is issued,
❑ 1 have and will maintain Worker's Compensation Insurnme, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Welke, Insu a merand Policynuilra�,.��
Carrier:FdTA'7_( ✓ Policy No.: / 20
CIibli MCAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundreddollars($1(10)
unless.)
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject m the Workers' Compen-
O z action Laws of Califomia. Date
.j O Applicant
NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should
a`tom' become subject to the Worker's Compensation provisions of the labor Code, you must
W by forthwith comply with such previsions or this permit shall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
U O (hereby affirm that here isaconwtruaion lending agency for the performanceof
LA F the work for which this permit is issued (Sec. 3097, Civ. C.)
O U Lenders Name
W Lenders Address
,fora L>w I certify that 1 have read this application and state that the above information is
F VJ correct. l agree to comply with all city and county ordinances and state laws relating to QTY
L% building construction, and hereby authodze representatives ofnis city to enter upon the
shove -mentioned properly for inspemion purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDE ND AND WI O 1PLY WITH ALL NON -POINT
SOURCE�R G6 / ��f�
Signature of �'3hcantsCU actor //J� Data
HAZARDOUS ATERIALS DISCLOSURE
Will the applicant orfutum building occupant score or handle hazardous material
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
QYes F1 No
Will the applicant or future building occupant use equipment of devices which
Lit hazmdoos air recominanta as defted by the Bay Arae Air Quality Management
District?- '
.
[I Yes []No .
I have read the hazeMnus materials requirements under Chapter 6.95 of the Cali -
(omit Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that if the
building does not currently have a unapt. Nat it is my responsibility td notify the cecupant
of the reyuir mems which must he met prior to issuance of a Certificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
201-10WAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECT'R
PLUMBING PERMIT
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-0VER 4 (EA)
0
COMMERCIAL:
CNEWBLDG/ADDITION []DEMOLITION
[]TENANT []FOODSERVICE
IMPROVEMENT
C OTHER
SQ
❑ ❑ o� ❑
FEE
JOB DESCRIPTION
DENTIA
RESIDENTIAL.-
C SFDWL ,, - El KIT HEN REMODEL
CADDFIION' MBING RE -PIPE
❑MULTI -UNIT ' []STRUCTURAL
MODIFICATION
C INTERIOR t C CHIMNEY REPAIR
IMPROVEMENT
C BATH RFMODEL/REPAIR' C DEMOLITION
C OTHER
"
-
STORIES''111VU
TYPEC(
COMMERCIAL:
CNEWBLDG/ADDITION []DEMOLITION
[]TENANT []FOODSERVICE
IMPROVEMENT
C OTHER
SQ
SQ. FT. FLOOR AREA
)ZtTION
)�I I[ t„.. o
TOTAL
P E
GRADING FEE
STORIES''111VU
TYPEC(
SOILS FEE
OCC. GROUP
PAID
TOR
BUILDING DIVISION FEES
GREASE TRAP
SEWER - SANITARY -STORM EA. 200 FL
WATER HEATER WNENT/ELECIR
WATER SYSTEMOBEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. ,SQ. P2
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I0,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD OVIDUCT)
HEATING UNIT CM 100,000 BTU)
HEATING UNIT (OVER RX1,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP DHP OR 100,000 BTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER.
NEW RESIDENTIAL MECH. SQ. ET.
OFFICE
LSQ. FT .
3
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
.Date Receipt N`
TOTAL:
BUILDING FEE
FEE
SEISMIC FEE'
ELECTRIC FEE
•
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dine Receipt k„
TOTAL:
3