S 3304APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - EcEcrRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL 3 3 0 4
❑ C .... Hand Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION QTY
I M1erehy affirm that I am Inueed under provisions of Chapter 9 (commencing
Jaz whnsecti�n7n o)nn>ivi,mn3m nam xa n en a nde,andmnyheenei,
F in full force and eRec, ` - V s
1, 0 ) a.
Q U U License Class—L c.Tl f
!�
Dw ARCHITECDECLARATION DsiCLARATION PV�.
Z-n z - - 1 underttanJ my plans shall he used! as public renndx
(- u�] Licensed Pron lional
•] OWNER -BUILDER DECLARATION
6 I hereby affirm that I am exempt from the Ca netuou's License Law for the
n. U following reason. (Section 7031.5, Business and I'm os,ions Cele: Any city or county
3 LL I- which requires a permit m cmear u, ulmr. improve, denmlieh, nr repair any structure
u'0Q prior nm its issuance, also requires me applicant fo,,mh permit to file a signed statement
that he is licensed pwsmanrtn,he provinomofthe Commcm/s Llcense Law (Chapter 9
Qfcmnmeneing with Section 7000) of Division Sof the Bu.cincaxand Professions Cock).,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
W .. y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
e marc than five hundred dahom (8500).
ESC ❑ Las owner of the property. or my cmployeec with wages astheirsnle compensation,
p., will do the work. and Ne w,C.u,a snot intended,,, mfered for sale (Sea. 7041, Uusiness
G 3 we and I'rnfessions code: The Gmmrunnr.c License Law does not apply to an owner of
property who builds or improves thereon, and who docs 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 issold within one year ofeampledinn, the
r-huilder will have the burden of proving that he did not build or improve far pur-
qrse of sola).
I, as owner of the pmpeny, an exclusively comexamg with licensed contractors 10
comoua the project (Sea 7004, Rie, ness unit Profession, Code:) The Cmuracmr's Li"
Came Law does not apply m an owner of property who builds or improves thereon, an
QTY.
who customers for such projects with a eommelc (s) licensed pursuvnt to the Contractor's
License Law.
L] 1 on exempt under Sec. , B & PC far this ...It
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby ul mai under penalty usperjury one of the following Workers
orkedeclarations:
a
❑ I have and will for by
atioCertificate700 of Consennn self Code, sure for erfonn, ce of ne-
the
vo,kf as hick this
for by Section 3]IXI of the Lalxs Cele, for the perfnnnance of rbc
work for welch this permit is orke.
❑ 1 have and will maintain he vour Compensation Insurance, h required , i Section
My ache Labors, ; for the perfnnmmnce of the work for which this permit is Issued.
yWmkgryCy p pinsyptc p -r ;Pold Policy gWtCcuvKw[l �[1
orrice �al/I�RR ICIRCAr Y � OF
FROM
OSVKWfRS [/
CIiHDFICCO OFCOMPENSATION
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be campleuJ Ifdme Pound Is Jerome hundred dollars Bllxq
or less.)
I cenifyt tin the pedormanceoOhcw ,which this pfrmil is ixwed,lsh,tll
nm emp p erste I scum cubjeclmmheWorkers'Cmnpcn-
O,z ,mint Lu sof C. dnmim.D 11
rj O Applicant
NOTIGIi O A a making this rti0cate of Exemption, you should
a bccnme stthjecr to a Workels Compencadinn provisions of the LaMu Code, you must
forthwith comply with such provisions at this pemtil shall b: decimal revoked.
ELECTRIC PERMIT FEE
PERMIT ISSUANCE f
APPLIANCES- BESIDE NTIAL
PANELS
UP TO 200 AMPS
201-10" AMPS
SIGNS ELECTRICAL
SPECIALCIRCUHUMISC.
TEMP. MH*fER OR POLI? INS P.
POWER DEVICES
SWIMMING POOL. ELECTRIC
36 "ef7y
I BLDG hi FLUMu mrLn
11 ❑ ❑ ❑
JOH DHSCRIY IIUN
RESIDENTIAL,
❑SFDWI.
.
❑ KITCHEN REMODEL.
❑ADDITION
❑ PLUMBING RE -PIPE
❑ MULTI UNIT
❑STRUCTURAL
WATER SYSTEM/TREATING
MODIFICATION
[I INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ HATH REMODEUREPAIR
DEMOLITION
❑OTHER
MECHAN ICA,'F
e
40 A
COMMERCIAL;
❑NIiW BLDG/ADDITION
❑DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
OU'I'LErs- SWI "TCI HES- FIXTURES e U
RU
NEW RESIDENTIAL. ELECTR SQ FE
1'LANCIILCK FEE
SQ. IT FL
WAI ER HEATER WNENTMLECfR
GRADING FEE
WATER SYSTEM/TREATING
PLUMBING PERMIT FEEPERMIT
ISSUANCE
W
tz CONSTRUCTION LENDING AGENCY
(.i 21 hereby affirm thmtheteisaconswmion leadingageacy lonm
he perforamc.f
iH the work far which this permit is issued (Sea 301 Co. CJ
C V land Name
W Lender's Address
y 1
!n umcnmagrrec mohmoI have wmiraed tilicilyumicounly
tion annd nam dcecms amhdo aabromve aiwnfsnnndn:wniinngn to
QTY.
V z building construction, and hereby authorize representatives
of this city Intents, upon the
above-mentioned property for inspection puHmses.
(We) agree to save, indemnify and keep harmless dhc City of Caperton .,am,,
Iiddlidies,judgmems, costs and expenses which may in anyway ri against said City
in nmqutame of rhe graining of this
APPLICANT UNDERSTANDS D WILL )MPLY WITH AL1, NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant stem or handle hazardous material
as defined by the Cupcnino Municipal Code. Chapter 9.12, unit the Health and Safety
CMc, Section 25532(n?
E] YC, [-I No
MWill the applicant or future building cecupunt use equipment ar devices which
t emit bluumb us air contaminants as defined by he Bay Arc. Air Quality Management
District?
E) YC' El No
1 have mad the ha sadous materials requirements under Chapter 6.91 of the Cali"
fomia Health & Safety Code. Sections 25505, 25533 and 2.5534.1 understand that if the
building docs not contrarily have a denwn, bad int is my....... hllity to ramify the u,.t
of the mquirenmenrs which must he not Poor,, issuance of a Cenifiea c of Ocen,i Icy.
Owner or itolmooed agent Data
ALTER - DRAIN & VEN f - WATER (IiA)
BACK FLOW PI �5
DRAINS -FCO )DELA iA.O D.
PIXTUHIiS-I' AP
GAS -COLS M-OVF.R4(EA7
GREASPIINI U�J" L WASTE INTERCEPTOR
RU
GRI? AS RAP
SI2WER- SANITARY - ST ORM IiA, 200 FT.
1'LANCIILCK FEE
ENERGY FEE .
WAI ER HEATER WNENTMLECfR
GRADING FEE
WATER SYSTEM/TREATING
SOILS FEF.
WATER SERVICE
PAID
nm,
NEW RESIDENTIAL PLMR. SQ. IT..
MECHANICAL PERM IT
FEE
BUILDING FEE
SHISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEB
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO '(III CPM)
MECHAN ICA,'F
AIR HANDLING UNI T(OVER 10AX) CFM)
CONSTRUCTION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION PER.
I ESUNG UNIT CTO 100.000 BU)
HEATING UNI "I (OVER 100.000 BTU)
PAID
VENTILATION FAN (SINGLE RESIDE
Dina Reccipr#
BOILER - COMP (311P OR 100.000 BTU)
T
HOI LER -COMP (OVER 100,00) BTU)
AIR CONDITIONER
ISSUANCE
I ~ 3 D ^'
DATE /7
z` -y(
NEW RESIDENTIAL MECH. SQ. FL