30221APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING, -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
_ I BUILDING PROJECT IDENTIFIC.
rBU1LDiNGADDRESS.
II ��325 I SUM I- LmsiE
30221
�RCUITECT/F�aGIN•ER:
LIC NO:
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ADDRESS:
❑
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nat 1 am licensed under previsions of Chapter 9 (commencing
with Section 4000)ef DivisionJaf the Business and Rofeuione Coda and my license is
in full force and effect.
License Class Lic.#
Date Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
FDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTFtER
—�=/per •-,.` g
PIiRMIT ISSUANCI?
APPLIANCES — RESIDENTIAL
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ARCHITECT'S DECLARATION
l understand my photostat] be se ed as public records
PANELS
UP TO 200 AMPS
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Licensed Prificoonal
OWNER-BUILDER DECLARATION
I hereby affirm Nat I um exempt from the Contractor's License Law for the
following reasma. (Section 701 Business mad PrefeW....s Cdle: Any city nrcunnty
which requires u permit to con.oract alter, improve, demolish, or repair any structure
pd., to its issuance,also retain the applicant for such pennitm fit easigned moment
thathe islicens pursuannnthepmvisionsofthe Contracmh Licenselaw(Chep,,g
(commencing with Section 4000) of Division 7 ofthe Business and Professions Code) or
he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 4011.5 by any applicant for a permit subjects the applicant ma a civil penalty of
not mote than five hundred dollars (5500).
[3 Las owner of the property, or my employees with wages as theirsele compensation,
will An the work, anal the swcmm is nm imm�Jnl oroffercJ fm wle (Ste. TIW4, 6unincss
unit Professions Cute: The Contractor's License Law docs 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 arc not intended or offered for
sale, If. however, the building or improvement is sold within one year ofcompletion,the
owner -budder will have the burden of'provdng that he did not build or Improve for put.
post of mled.
0 1, as owner of the property, not exclusively contracting with licensed contractors 1.
construct the project (Sec. 704, Business and Frolicsome Code:) The Contractor's Li.
c se Low does notapply to an owoerof property who builds or improves thereon,and
who contracts for such Fri with a contractors) licensed pursuant to the Commetors
License Law.
em exemptunder Sec.
I ,B&PCforthis reason
Owner Unte
201-1000AMP5
OVER 1000AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCULT/MISC.
'THME. METER OR POLH INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOLELECfRIC
OUTLETS —SWITCHES —F TURF.
NEW RESIDENTIAL ELE, SQ
SQ. FE 14.00R AREA
b
I- �(��
A 7
$/SQ. FT
T
qry.. PLUMBING PERMIT FEE
PERMIT ISSUANCE
AUFHR— DRAIN & VENT— WATER IEA)
LUATION yrs
3 1 (�
, VJ
WORKER'S COMPENSATION DtCLAI&TION
affirmPROTECT.
• I hereby an under penalty of perjury one ofthe following declarations:
❑l have and will maintain a Cenificme of Conent to self -insure for Wmkcrs Camper.
action, on pnrvideA for by Section 311#1 of the Labor GWe, for pelbm
the rnnca of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurfam. as impaired! by Swain
77M of Ne labor Cole, for the performance ofthe work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number au:
Currier: Policy Na:
CHRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(Thissection necdnoloccomplevd lfthepemait isforenehundteddmllars($100)
or less.)
(certify phutinthe anyimaa.nceoas t work for subject
ich jethio the it Wixissued.lshaller.
' not employ any person in any manner so as m become subjen to the Workers Compen-
O Z nation laws a CvBfords. Date
�r.2 Applicant
w7 LA NOTICE TO APPLICANT: IL after making this Cenifium of Exemption, you should
(•^ t"' become subject to the Worker's Compensation provisions of the labor Cafe, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
aQ
CONSTRUCTION ].ENDING AGENCY
U (hereby ufftrm that there isamnstmmion lending agency fonhe performance of
OP the work for which this permit is issued (Sec. 71197, Ci, CJ
I--' Lenders Name
WLenders Address
j},st I certify that 1 have read this application unit state that the move information is
i.. VI correct l agree to comply with all city and county ordinances and state laws relating tit
UZ� building conswction, end hereby emhonurc,rcsenmtivex efthisciry menterupon the
above-mnnioned property for inspection purposes
(We) agree to save, indemnify end kac, baraluss t e City of Cupeulno.,.last
liabilindes,judgmenm, costs and expenses which may in any way some against said City
in asequence of the granting of this Permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
BACK FLOW DEVICE
DRAINS—PLOOR,NOOs,ARFA, GOND.
STORIES
OCC. GROUP
_
T YPE CONSTRUCTION
cJ
rT`RIQ—
ANN
FIXTURES — PER TRAP
GAS—EA. SYSTEM -1 INC.4 OUTLETS
GAS — EA. SYSTEM -OVER 4 (EA)
GREASE(INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FI?BS
GREASE TNAIs
-
PLANCHECK FEL'
S12WER—SANITARY—STORM EA. 210 FT.
ENL'RGY FEL
WATER HEATER WNENT/ELECfR
GRADING FEE
WATER SYSTEMITREAT'ING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDISNTIAL PLMB. SQ, FT.
Dale Receipt,
TOTAL:
TOTAL:
BUILDING FEE
s v�
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
,S
PERMIT ISSUANCE.
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
ABR HANDLING UNIT (TO Iff" CFM)
MECHANLCALFEE
AIR HANDLING UNIT (OVER 10,1011 CFM)
CONSTRUCTION TAX
Signature of ApplicandCoureacmr Date
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rimapunt store or IFmdle hazardous material
an defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25572(a)T
❑Yes [I No
Btuseea Air uterdeviceswhich
Will the applicantorfmure building by
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
E] Yes No
I have reed the hazamloas materialsAIR
requirements umkr Chapter 6.95 of doe Cali-
fornia Health & Safety Cede, Scene. 23505, 25511 and 25574.1 understand Nat if dm
building does not currently have a tenant. that it is my milaccohility to ratify the.,ant
of the requirements which must he mr(,n.r to issuance at a CeriOcme mf Occupancy.
EXHAUST H())D(W/DUC)
HOUSING MITIGATION FEE
I IHA'TING UNIT (TO I00JIa) BTU)
HEATING UNIT (OVER I0ft" BTU)
PAID
VENTILATION FAN (SINGLE RE,SID) -
Date Receipt#
BOILER— COMP(7HP OR 10,f100 BTU)
TOTAL:
BOILER—COMP (OVER IIO,(Op BTU)
,
CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE