29894APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL - PERMIT NO. 2 9 ^ ^ /I
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL - L lXJ 4J 4
❑ Consultant Fees Paid by Applicant (Initial)
I hereby union that I am licensed under provi—as of Chapter 9 (commencing
OZO wiih Secamn xXn d l cion 3ofine Bminessand Pry(efsigCod,and Iny Be
QUin full fox and 'ect. (�' yl ItV_L
U Licen
yZ W Dam Conus
ARCHITECTS DECLARATION
Z O w m I understand my plans shall Leaned! as public recoMs
0Z_Z
Gt_ W Licensed Professional
y
yf.� OWNER -BUILDER DECLARATION
C C 6 1 hereby affirm that 1 aexempt from e Contractors License Law for Lie
31 m th
U following mann. (Section 703 L5, Business and Professions Code: Any city of county
ul O y which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to rile a signed statement
} that he is licensed pursuant o the provisions ofthe Contractor's License Law (Chapter 9
WCC -'00 (commencing with Section70had of Division 3 ofthe Blninessrnd Professions Code)ot
y W o K that he is exempt therefrom and the basis for the alleged encianion, Any viclofmn of
all Section 7031.5 by any npplicam for a peon subjects the .ppliuun In u civil penalty of
zCnot more than rive hundred doll... ($500).
❑ I, us owner of the pmpeny. or my etnpinyees with wages as their sale compensation,
will it,, the work, and lhcslmcmre is not intended or offered lin sale(See7014, Business
Lid 3 m and Professions Codd The Contractors License Law does nor apply to on owner of
property who builds or improves thereon, and who docs such work himself or through
his own employees. provided that such improvements arc not intended or offered for
sale, If, however, the building sur imprm'ement is sold within one year of completion, the
owner -builder will have Ute buNen of proving that he did nm build or improve for pur-
pose of sale.).
I, as owner of the pmperf, , am exclusively convecting with licensed committers to '
construct the project (Sm. 7044, Business and Professions Cod,:) The Contractors Li
c nae Law does act apply to an owner of progeny who builds or improves themon. and QT`F
who contracts fm such Limiters with a comma..(.) licensed pursuant to the Contractor's
License law.
rOwnmempt under Sec. B & P C for his memo
Tate
WORKER'S COMPENSATION DECLARATION
ereby affirm under penally of perjury one of the hollwing declarations:
anaillmai.minor
far by Scotian 3700 of the Lebo. Code, lin the performance of the
work for which this permit is issued, "
1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofthe Labor Code, f.r the performance .fine work for which this permit is ismed.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy Na,:
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need nut be completed if the permit is (mane hundred dollars (5100)
or las.)
1 cer ify that in the perfommnce of rhe work for which this permit is issued, I shall
not employ any person in any manner so as to become subject t0 the Nbrkers Compere
QZ an.. laws of CalilLmia. Dole
Z C Applicant
Liss NOTICE TO APPLICANT If, after making this CediOcete of Exemption. you should
a, become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions cartons permit shut] be deemed revoked.
As
U z CONSTR UCTION LENDING AGENCY
U O l for
chiI hi permithat
ssued(Secn3 lc. ding agmtryTim the pcA'onnnnea of
fLH the work Na which lhixpermit ixiasurd (San. 309T,Ci¢CJ
(] U Lender's Name
Lender's Address
H0. 1 certify than I have read this application and ,am that the above information is
h coned. I agree to comply with all city and county ordinances and state laws relating to QTY.
V Z building convection, and hereby authonee representatives of this city to enter upon the
shove mentioned properly for inspection purposes.
(We) agree to ave, indemnify and keep harmless the City of Canadian against
liabilities, judgments, costs and expenxs which may in any way acerae against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicantlContracmr Date
HA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding eveupam.nom or handle hanadbua mmeriul
as defined by the CujerinoMunicipal Code, Chapter 9.12, and the Health slid Safety
Case, Seetin i 25532(.))
❑Yes El No
Will the applicant or future building occupant use equipment or devices which
1r it in ealloex air conmminams as defined by the Bay Area Air Quality Management
-1 yes Fl No
1 have mad the Interactions materials requirements under Chapter 6,95 of the Cali -
boom Simon As Sidetyibthe,-S�tc�55Q5. 25533 and 25534. 1 understood Nat if use
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UPT0200AMPS
OVER ["AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL III.IICI NIC
OUTLETS - SWITCHES - FIXTORES
TR SQ ET.
BUILDING PERMIT INFO
$/SQ. FT.
qLr
njapcL ELECT PLUMB - All
IJIJ�
PERMIT FEE
FEE
JOB DESCRIPTION
RESIDENTIAL
C SFDWL C KITCHEN REMODEL
CADDITION El PLUMBING RE -PIPE
C MULTI -UNIT El STRUCTURAL
MODIFICATION
C INTERIOR C CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEDREPAIR ElDEMOLITION
❑OTHER I
-
r������ H
OA-Ihf�F.R IA
C NEW, BLDG/ADDITION, It El DEMOLITION
CTENANTI Vit .. ElFOOD SERVICE
IMPROVEMENT
C O'THF.R
TR SQ ET.
SQ. Fri. FLOOR ARE
q 9
$/SQ. FT.
qLr
TOTAL:
PERMIT FEE
ALTER- DRAIN & VENT- WATER (EA)
BACKFLOW PROTECT DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM. I INC. 4 OUTLETS
GAS- EA, SYSTEW-OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER W/VF.NTMLECTR
WATER SYSTEMOREATING
WATER SERVICE
NEW RESIDENT IAL PLMB. 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 HOOD (WMUCT)
HEATING UNIT (TO too.oco If ru)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE RESIDE
BOILER - COMP (3HP OR I 00.0flX1 BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
OFFICE
SQ. FT.
0�
I BUILDING DIVISION FEES
PLANCHECK FEE '
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Reccipl#
TOTAL:
BUILDING PEE k, 1
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Receipt#
ISSUANCE DATE
1 M a/