S 0122APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPER FINO BUILDING - ELECT RICAL IT.§fr NO 1
NUILDINGDIVISION APPIACATION/PERMIT PLUMBING - MECHANICAL J O1ZZ
............. ..........„ ",-vm.....,,.... . 1
11e� �.�t1 �f fJ` �5U ❑
1g119:L11
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 herehy.Norm that 1 am licensed under provisinre nt
of Chapter 9 (emnencing
with Section 701go of Division 3 of,hc Business and Prdesdons Code, and my license is
in full force anJiB'n
I.1cense Class S�� Lie.. p
Dm�Cmmmtrmm CL Fr
ARCHITECTS DECLARATION
1 undersand my plans shall Be tread as public-ceords
OWNER -BUILDER DECLARATION
I hereby affirm that ) am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Rusions and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or mpair any structure
prior in its issuance, also tvquires the applicant for such permit R, file a signed statement
that he is licenced punuanuo the p ,, isinnv of the Contmcmr'e License Lnw (Chapter 9
(commcne ing with Section 7090) ofD.,ow.3 of the Business and Profesviam Code) nr
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section TD15 by any applicant for o Permit .subjects the applicant to a civil penalty of
not marc than five hundred dollars 1$50101.
❑ 1, as owner of the prper y. or my employees with wages auheir sole compensation.
will do the work, and the interim is not Intendedor offered for sale (Sec 7144. Buninetts
and Professions Code: The Commmors License Law docs not apply to an owner of
property who builds or improve% thereon, and who does such work hicowd or through
his own employees, providul that such Imp-woucc s arc not intended or offered for
sale. IL however, the building or improvement is sold within one year- completion, the
owner -builder will have the burden of pswing that he did not build or Improve lin pur-
pose of sale.).
1, as owner of the property, am endu%ivcly contracting with licensed contractors to
onstruct the project (Sec. load. Business and Frofincomn C(de:) The Contractor's Li -
croon Law does not apply to an ownerof property who builds or improves meson, and QTY
who contracts for such project, with a contranor(s) licensed pursuant to the Contractor's
Lice ao Law.
1 am exempt under Sec. . B & P C for this reason
Owner Ilam
WORKER'S COMPENSATION DECLARATION
1 herehy, affect under penalty of perjury one of Ne following declarations:
❑ I have and will maintain a Ceniticate of Conscnun s,ifinsure lit- Workers Compen-
sation, as provided for by Section 371X1 of the Lahr Cole, for the performance of the
w
for which this permit is issued,
have and will maintain Workers Compensation Laurance, us required by Section
7110 aft 1,,idwr CrwR for'
�c, �erQfo�r�manccof Lhew'orkfurwhicht i permit is issued.
parcafid
com
Of litab
C�Wm .v a1 CERTIFICATE 9F EXF.MPHPolicy No.,
ON FRO W R, `[`�ibSN7
COMPENSATION INSURANCE
(Diissecrwn need not he completed if the permit is for one handiest Jnllers 15100)
o -less.)
1 cenlfy that in Ne performance of the work 1'or which this permit Its issued, l shall
not employ any pcaon in ony manner so ns to become suh co m the Workers' Compen
Z s rmm Laws of Callfnmia. Date
C Applicam
NOTICE TO APPLICANT: If, after making this CeniBcam of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cole, you must
Forthwith comply with such provisions or this permit shall be deemed revoked.
a�
CONSTRUCTION LENDING AGENCY
U work
Nut them isaed(Sec. constructionleadingagency for the Perfnnnvnccof
F-' the work fm which this permit is issued (Sec. 3(19], Civ. C.)
OLenders Name
U
4nJcr'.s Address
I cenify that I have mad this application and state Nat the above information is
H y correct. l agree to comply with all city and county ordinances and state laws relating to QTy,
U Z building construction, and hereby authorim reprccemativesofthis city tocnter upon the
aWvumentioned Property for inspection purposes.
(We) agree u) save, indemnify and keep harmless the City of Cupor,i art against
Iiahiluiecjndgments, costs and expenses which may in any way arrive against said City
in onnequcnce of the granting of chi%permit.
AP `L ANT UNDE TANDS AND W ILL COMPLY Willi ALL NON -POINT
St lI 'E
RBGULA06NS.
�- fl-5�
Signaw
HAVA wdAppliwD Or Du,
HAlARIIOUS MATERIALS DISCLOSURE
Will the eCic,temtr Tamm buildinge, Chapterreor handle hazardousd Sauey
m de. Sed by ,he Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Gila Section 25512(a)l
❑Yes Fl No
Will the applicant or future Wilding occupant use equipment or device%which
cion bvardow air comm ouracts as lefinul by the Bay Arca Air Quality M:magemcnt
Di,wdct,
❑Yes F1 No
I have mad the htzvJoux mammals "maccuents coal Chapter h.95 of Ne Cali -
forma Health A Safety Calc. Sections 25505, 25533 and 25534. 1 understand chat it"the
building does not currently have a mount, that is is my responsibility to nociry,he occupant
of the ruirementn which mus, to mel prior , issuanceofa Certificate of Occupancy.
ELECTRIC PERMIT
FEE
PERMIT ISSUANCE
❑ SFDWL
APPLIANCES — RESIDENTIAI.
❑ADDITION
PANELS
UP TO 200 AMPS
❑MULTI -UNIT
201-I010AMYS
OVER light AMPS
❑INTERIOR
SIGNS F.LF,CTRICAL
IMPROVEMENT
SPECIAL CIRCUIT/MISC.
❑ BATH REMODEUREPAIR ❑DEMOLITION
TAMP. METER OR POLE 'I'.
POWER DEVICES
SWIMMING I. ELECTRIC
OUTLETSWITCHES—FIXTURES
NE ISIDEWIAL ELECTS SQ PT.
TOTAL:
/
PLUMBING PERMIT
FEE
PERMIT ISSUANCE
ALTER— DRAIN k V ENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF. AREA, COND,
FIX 'I'UR17S — PER TRAP
GAS —IiA. SYSTEM-] INC. 4 DO FLETS
GAS — EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER—SANITARY—STORM IiA, 20k1IT.
WATER HEATER W/VENT/ELECTR
WATER SYSTF.MaREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. EL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO I03ga)CFM)
AIR IIANDLING UNIT (OVER 10.000 CPM)
EXHAUST HOOD 100/DUCq
HEATING UNIT (TO I(Xvion BTU)
HEATING UNIT (OVER IN ),( BT(])
VENTILATION FAN (SI 'LE RESID)
BOILER —COMP 1 1' OR 100.000 BTU)
BOILER—CO (OVER 1(10,00(1 BTU)
AIR CONWifilONER
NEW RESIDENTIALMECH. SQ. FT.
OFFICE
BUILDING PERMIT INFO
BLDG I71 -ECT PLUME MFCH
❑ ❑ j?1 ❑
JOH DFSURIFI IUN
RFSIDENT'IAL
❑ SFDWL
❑ KITCHEN REMOD17L
❑ADDITION
0PLUMBING RE -PIPE
❑MULTI -UNIT
L3 STRUCTURAL
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
I] SWIMMING P(X)IS
❑ BATH REMODEUREPAIR ❑DEMOLITION
COMMERCIAL:
[I NI?W BLDG/ADDITION
❑ TENANT
IMPROVEMENT
❑ OTH]:R
❑ DEMOLITION
❑ FOOD SERVICE
VALUATION
BUILDING DIVISION FEES
PLANCI IECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dive Receipts
TO"I'AI.:
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING THE
MEC11ANICAL FEIi
CONS I'RUCTION '1AS
HOUSING MITIGATION FEE
PAID
Dale
TOTAL:
$/SQ. IT.