29002APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO RmLo1NG - ItAAAk RILAL rercmu nu.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL. 9002
❑ Consultant Fees Paid by Applicant (Initial)
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing - with Section 7080 of Division 3 of the Itusiness and /Rko/f�e,qm�os•�rCo]]de, and my license is
in mll'coca sod of N �Q0r
Liceroe Clae LiC.a +p
Date Contacmr ARCHITECT'S DECLARATION
I understand my plass shall be used as public records
Licensed Profen,lunaI
OWNER -BUILDER DECLARATION
1 hereby affirm Oat I am exempt from the Commemr's Liceroe Law lid rhe
following reason. (Section 70315. Business and Professions Code: Any city or-eommy
which requires o permit to construct, alter, improve, demolish, or repair any %racture
prior to its ismantt, also requites the applicant for such permit to file a signed statement
that he is licensed pursuant to Ne pmvisiuns of the Contractor's License Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit .subjects the applicant m a civil penalty of
not mare than five hundred dolls, S56).
❑ Las owncroflhepmpedy, ormy enfployces with wages as theirselecomlommlon.
will de time work, and the swnurc is not intended oroffcrtd for sale l$ec. 70X, Business
and Professions Code: The Contractors License law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees. provided that such improvements art not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
o er-builder will have the burden aT proving that he did not build or improve for pen
poserrolr.Y
❑ 1, as owner of the progeny, am exclusively contracting with licensed contractors to
consumer the project (Scc. 7614. Business sad Profession, Crde:) The Com actors Li-
ce Law Jms nm apply je an with
a of mprpcdyaeowho builds or improves Norton, and QTY.
whoo contacts ha each protects with a cor(s) licensed pursuant m the Conwctor'.v
License law.
❑ 1 am exempt under Scc. . N & P C for this reason
I Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaations:
I have and will maintain a Certificate of Consent to self-insum for Workers Compen-
some, as provided for by Section 37M of the Labor Code, for the performance of the
..,it for which this permit is issued.
❑ 1 have and wilt mai main Workers Compensation Insumme , as required by Section
3700 of the Luvir Cock, for the perrormance of be wait fm which this perms Is Issued,
My Worke�s Ctampcnsaiom srntt curl and Policy gWYG
Cemiev )x/Orhwr nnn.l'oEcy No.: �L90J0 G
CERTIFICATE OF CXEMPTION FROM WORKGRS'
COMPENSATION INSURANCE
(7Tis.section need not he completed if Ne permit is for one hundred dollars (51110)
or less.)
1 codify that in the performance of the work for which this permit in issued., shall
not employ any person in any manner so as to becomesubject in the WorkersCompen-
Z sumn Laws ,I California. Data
Z O Applicant
N NOTICE TO APPLICANT. If. after making this Cerificate of Exemption, you should
a; become subject to the Workers Compensation provisions of the labor Code, you must
{✓:1 forthwith comply with such provisions or this permit shall be deemed revoked.
Q
CONSTRUC'I1(lN LIiNI51NG AGENCY
U OIhereby al firm that there iso rmomcdom lendimg agency fmahe Performance of
P the work far which this per mit is issued (So,. 3097. Civ. C.)
O U Lenders Name
W Lender's Address
1 certify that 1 have read this application and sate that the above Information is
faq cored. 1 agree to comply with all city and county ordinances and state laws relating to
U buil ding csmmmefioo, and hereby mahoriac representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
(Wq agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in ,sequence of no gramim, of this permit.
APPLICANT UNDERSTANDS AND W ILL COMPLY WITH ALL NON -POINT
SOURCE r'ULATIONS
�!� /-/677N
Signature of ApplicarUConuace7 Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building tasseled, nos, or handle haardons material
as defined by be Calamine Municipal Cade. Chapter 91 12, and the Health and Safety
Code, Section 255321a)7
.99aba C3 Yet Fl No
WDWill the applicant or future bit Ming occupanl me 11mlarenf err davices which
,Mt hazmdnus air contaminants as dined by the Bay Arca Air Quality Management
inner?
❑Yes El No
1 have read the hazardous malends requirements under Chapter 6.95 of the Cali.
(umbo Health & Safety Code, Sections 25505, 25533 and 25534, 1 undersand that if the
building does not commently have u lament flet X Is my r gwneibility to notify the ruupum
of the requirements whim must he stet prior III issuance set a Cenircale of Occupancy.
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES— RESIDENTIAL
PANELS
UPTO 200AMPS
SIGNS 17LECHOCAL
SPECIAL. CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—POSTURES
NEW RP_SIDENTIALELECIR kV SQFT.
PERMIT ISSUANCE 2
ALTER —DRAIN&VENT —WA U:
BACK FLOW PROTECT. DEVICE /
DRAINS — FLOOR, ROOF, AREA. GOND.
FIXTURES — PER TRAP
GAS — EA,. SYSTEM 1 INC 4 OUT
GAS — PA. SYSTEM -OVER 4IEA)
GREASEIINDUSTRL WASTE INTERCEPTOR
GREASEIRAP
SEWER — SANITARY — STORM EA, 260 IT
WATER HEATER W/VCM/ELECTR
WATER SYSTEMII'REATING
WATER SERVICE
NEW RHSIDENTIAL PLMII. SQ, P1'.
TOTAL
QTY. MECHANICAL PERMIT
PERMG ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ITO to." CF,W
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD IW/DUCT')
HEATING UNIT (TO 100,0011 BTU)
HEATING UNIT (OVER 100,0110 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER — COMP EHP OR 1(0.1010 BTU)
BOILER — COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ, FT.
0
❑ ❑
Vii
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL
❑ KI' I'CHN REMODEL.
❑ADDITION
❑PLUMBI.NGRE-PIPE
[:1 MULTI -UNIT
❑STRUCTURAL
h DIFICATION
❑ INTERIOR
IMNEY REPAIR
IMPROVEMENT
❑ BATH RF,MODEI/REP[sI4E1
DEM LITQION
[3 HER 1Y
Opt U�"(is[�
1%tlra�4.r,t_
i
COMMERCIAL
EI NEW BLDG/ADDITION El DEMOLITION
[]TENANT ❑ FOOD SERVICE
IMPROVEMENT'
❑OTHER
g✓•
STORIES
BUILDING DIVISION M71-9
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Data Rdceipt it
BUILDING FEE
EEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
I MECHANICAL FEE I
I CONSTRUCTION'I'AX I
I HOUSING MITIGATION FEE I
PAID
(late
Owner or audmomW agent Dae TOTAL:( IISSUED BY:
OFFICE
$/SQ. PT.