26324(CITY OF CUPERTINO APPLICATION/PERMIT PLumxiric. meclineicnL "'." 263241
BUILDING DIVISION BUILDING. PR(yJECT IDENTIFICATION
LICENSED CONTRACTOR'S DECLARATION
I het<by affirm that Ion licensed under, pmvisions of Chapter 9 (commencing with
00) o
Section 70f Division 3 of the Business and Professions Cade, and my license is in
full force and effect.
License Class Lic.is
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm But 1 oat exam,, from the Convectors License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city ter county
which equlres a permit to construct, alter, improve, demolish, or repair any stromure
prior to its issuance, also rums the applicant for such permit to file a signed moment
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter
9 (commencing with Section 7") of Division 3 o the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
SectiogR7031.5 by any, applicant for a permit subjects the applicant 1. a civil penalty of
allla� than five hundred dollars ($500).
willdatftwork, and the structure is not imcndedm ifferid hassle (Sec.]044, Business
sad Pmfessionv Code: The Contractors License Law does not apply no an owner of
pmpertywhobuild.mimpeva thereon.and whodoes such work himselforlhmughhis
own employes, provided that such improvements arc nal intended or offered for sale. If.
however, Ne building m improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
silt.).
❑ I, m owner oftbe property. amexclusively connecting with licensed contractorsto
comwcn he Project (Sec. 7144, Dust.. and Professions Code:) The Connector'.
License Law does not apply tom owner of property who builds or improves Hereon,and
whocontracis for such projects with a wntractor(s) licensed pursuant to the Contractor's
License Lew. _ QZQ V 5
[II am exempted<r Sec , B & P C for this rcwon
WORKMAN COMPENSAT SIN DECLARATION I
1 herehy affirm mm I have a certificate of mascm no self-insue, or a anificne of
tori Compensation Insurance maartified copy thereof(See. 3800, Lab CJ which
s all employee's under his permit.
❑ Cendiaimpynherebyfumished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fortune hunerddollan ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued. I shall
not employ any person in any mama .o as to become subject no be Workers'
z Comns
peation Law. of Colifomiam
. Data
Applicant
7� 0 NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
FIn become subject to the Workers Compensation provisiom of the Labor Code, you must
K, 7 forthwith comply with such provisions or this permit shall b, deemd smoked.
Z
CONSTRUCTION LENDING AGENCY
.-1 1 hereby affirm that there is a construction lending agency for the performance of
O the work far which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
LL. j-^ Lenders Addmu
W 1 certify that 1 have mad this application and state that the above informalion is
correct. l agree to comply with all city and county ordinances and state laws relating no
�+ building construction, and hereby emhmire mpmseundves of this city no enter upon the
U z above-mentioned property for inspection purposes.
(We) agree no save, indemnify and keep hmmlea. the City of Cupemimo against
liabilities, judgments, costs and expenses which my in any way acerae against said City
in consequence of the grunting of this permit.
Signature of Applicant/Contmctm Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fum a building occupant store or handle harardous material
m defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Code, Section 25532nd?
❑Yes 9No
Willthe applicant or future building occupant use equipment ordeviers which emit
������uuwwwwttmotors air contaminants m defined by the Bay Area Air Quality Management
strict?
II ❑Yes i No
1 have read the Intonations materials raquiremrnrs it,, Chapter 6.95 of Ne
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand Nat
if the buiWingd cuyyaa lyh men t, that it is my msponsibility to notify the
rccupant o uiy6j)N A i0
9 met prior to issumee of s Certificate of
QTY, ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCU TIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
PUTLETS - SWITCHES - FIXTURES
_SQ. PT.
PLUMBING PERMIT
PERMITISSUANCE
ALTER - DRAIN & VENT - WATER (PA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA. COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFJINDUSTRL WASTE INTERCEPTOR
GRBASETRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEM/IREATING
NEW RESIDENTIAL FUME. SQ, FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST FOOD (W/DUCT)
HEATING UNIT (TO 100,100 BTU)
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH.-SQ, FT.
TOTAL:
FEE.
FEE
FE
:_ 0
FEE SUMMARY
PARK FEE YN
RECEIPTN
BUILDING DIVISION FEES
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Date Rmeipi N
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
C