S 0330APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL PE§ IT NO Lek I(�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL O J V O
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am license under Provisions Of Chapter 9 (commencing
with Smuan ]mpef Division 3 ofrhe Business and Pmfec ions Cal% and my license is
Leraseull lass d lTec� iD ZZ�
License Class Contractor
ARCHITECTS
'f
ARCHR[CPS DECLARATION
I understand my plans shall h use s public records
pg X:! OWNER -BUILDER DECLARATION
a 94 G 1 hereby affirm that 1 am exempt from the Contractor's License law, for the
6 U following reason. (Section ]031 ,5, Business and Professions Gale: Any city or county
Wla,WhichW hlch requires a permit to mutual, alter, Improve. demolish, or repair any nmclure
...]]] prior to its issuance, also requires the applicant far.such pemdt m rile a signed statement
,�y Nal he is licensed pursuant to the provisions of the Conunmor'sLicares,UW(Chapter 9
CA (commencing with Section'1000) of Division 3 of the Business and Professions Cade) Or
ly m that he is exempt therefrom and the basis far the alleged exemption. Any violation of
Y%1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
t marc than five handled dollars ($500).
Q Q L as owner of the property, or my employees with wages as their role compensation.
will do the Work, and the structure is nut intended or offered for sale (Sm. 70,14, Business
6 3 $ and Professions Cale: The Contractor's License Law does not apply to an Owner of
properly who builds or improves thereon, and who docs such work himself or through
his own employees, provide that such improvements an, nal intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
cwvrao-buildcr will have the burden of proving that he did not build or improve for pur-
pose of sated.
I, as owner of the property, am exclusively contracting with licensed contractors to
onnrud the project (Sec 7034, Business and PrafeWor s COdc:) The Conlracmr's LI-
nse Use does not apply to an owner of progeny who builds or improves Ihemon, and
who contracts for such projects with a contractor(&) licensed pursuanuo the Commemes
License law.
1 am exempt under Sm. . B & P C for this Mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
., ❑Ihave pro will for
Section
20te ofCunseuorCode,forefnrWmkmanceipen-
&alinn, as provided for by Section J] W of the Lahr Code, for the performance if 'he
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insumnce, as required by Section
3700 of the Labor Gide. for the performance of the work for which this permit is issued.
CERTIFICATE: OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
ELECTRIC PERMIT FEE
PE'RMI'TISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
UPTO 200 AMPS
OVER 10(10 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUII'/MISC.
ERNE. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTI,FTS — SWITCHES — FIXTURIS
NEW RESIDENTIAL ELECTR
(This section nrednm hecompleted iflbe permit is fornne hundred dollars (SIaB
(certify thatinthe performanceofrhe ..,it for which this ,air is ersCoIshnll
oat employ any person in any manner so os to become subject m the Workers' Cnmpen-
Z section Laws Of California. Date
O Applicant \ .
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
a � become subject to IM1e Worker's Compannadun provisions of the Lana Code, you must
fy fordiMlh comply With such porshiom or this permit shall he decided revoke.
Q
CONhem is af1ON LENDING AGENCY
C.) (forthereby affininWhihthi hot them issued grmionlending agency for perfnmunce of
� (~ IM1e work for which This permit is issued (Sec. 3Y37, Co. C.)
Q U(.enders Name
Lender's Address
y 1 certify that 1 have read this application and state that the above information is
V) fence. l agree to comply with all city and county ordinances and nate laws relating m QTY.
U Z building mnsauction, and hereby authorize lepreselnalivs, of this city to'
upon Ne
abov mentioned property for inspection Purposes.
e (We) agree m save, indemnify and keep harmless Ne City Of Culmina ngainsl
liabilities. judgments, costs and expenses which may in any way starve against said City
in consequence of the loaning of this permit.
APPLICANT UNDERSTANDS AN ILL COA1P f ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as define by the Cupenino Municipal Code, Chapter 9.12, and the I lcalth ..it Safety
Cee, Section 25532(a)]
Y. rNo
Will me applicant or future holding Occupant use equlpro a or devices which
mit hazardous air contaminants as deFlned by the Bay Arca Air Quality Management
District?
❑Yes L] NO
I have read the heraNms ma2rial& requirement. under Chapter 6.95 of the Cali-
fornia Health & Safety Code. Sections 25505. 25533 must 25534. 1 understand that if the
building does not currently have a team, that it is my msrymsibility to notify the occupant
of are rquirements which must he met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Data
PLUMBING PERMIT
P17RMIT ISSUANCE
ALTER —DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS —FLOOR, ROOF, AREA, COND.
FIXTURES—PER TRAP
GAS—EA. SYSTEM -1 INC. 4 OUTLIfTS
GAS — P.A. SYSTEM -OVER 4 TA)
GREASMNDUSI'RL WASTE I NfERCF.PTOR
SEWER—SANITARY—STORM EA, 2W IT.
WATER DEATHS WNENI'/IiLECI'R
WATER SYSTEM/TREA'IING
WATER SERVICE
NEW RESIDEN I' IAL PLMB. SQ, ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IBUW CFM)
AIR HANDLING UNIT (OVER W.000 CFM)
EXHAUST GOOD(WIDUC)
HEATING UNIT' (TO 100,000 BTU)
HEA'HNG UNIT (OVER 100,111)(1 BTU)
VENTILATION FAN (SINGLE REMO)
BOILER—COMP 0HP OR 100,000 BTU)
BOILER —COMP(OVFR 103,000 BTU)
AIR CONDITIONER
NEWRESIDENTIALMECIL SQ. FT.
0
9❑ C�I 1 L❑ H m❑n
RFSIDENIIAL
C SFDWL
C KITCHEN REMODEL
El ADDITION
CPLUMBINGRE-PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ BATH REMODPL,`REPA
DEMOLITION
❑OTHER
COMMERCIAL,
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
*'Z` rr
FEE
JUTts%1 �
11N(
CITY Ur 600th
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEF.
GRADING FEE
SOILS FEE
PAID
p
TOTAL:
OUILDING T -
FEE SEISMIC FF.
F.LF.Cf"C FFE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FIRE
PAID
Dale —__T_eeno#