99100141APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
CITY OF CUVERTINO BUILDING.
1119LDING DIVISION APPLICATIONIPERMIT PLUMB
RO -
uuu.DINrnG PxaEc
RDILDINGADDRFSS: I /
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CONTACT.
LICENSED CONTRACTOR'S DECLARATION
I hereby ollirm that I am licensed under transitions of Chap
aO Zp with Section 7000) of Division 3 ofrhe Business and ProfesSUP
an pill force and enact.
Un License Class Lic.4
1 understood my plunx shall be used as public records
NAME:
❑ Consultant Fees Paid by Applicant (Initial)
5-� OWNER - BUILDER DECLARATION
G e�1 1 hereby affirm that 1 am exempt from the Contractors License Law for the
' L U following reason. (Section 7031,5. Basin.,, and Prom....... Gdu: Any city ... ... only
O h which requires. permit to eonsmen, ape,, improve, demolish, nr repair any someone
prim m its issuance, also requires the iii,du ant for such permit to file a signed statement
y�}Bad he is licensed p.,soanno the provisions of the Contractors license law(Chapter 9
Y0� Icommeneing with Section 7000)of Division 3 of the BV,i ties, and Professions Cade) or
c C that he is exempt therefrom and the hisis for the alleged exemption. Any violation of
' a Section 7031.5 by any applicant for a Permit subjects [lie applicant to a civil Penalty of
`o n more than rive hundred dollars ❑ 1, as owner of the propeny,or my employees with wages as their sole compensation.
will do the work, and the structure is not intended orotfard for salm(Sm. 7144, Business
^ °m and Professions Cubp The Commuslor's License Law does not apply to an owner of
L 3 property who build or improves thereon, and who does such work himself or through
his own employees, provided that such improvements ore not intended or offered for
sal.. If, however, the building n, improve neat is sold within one year of complulion, the
wncobuilder will have the burden of proving that he did not build or impose tin pu,-
pom of sale.).
❑ 1, at r of the property, am exclusively contracting with licensed contractors to
ms(,uct the pojeat (Sec. 7144. Business and Professions Code:) The Contnstuds Li-
censeLawdoesnotapplytoanownerofpropemywhohulldsmrimprovesthereon ,and Q'PY.
who contracts for such projects with a commmorls) licensed pursuant to the Convectors
License law.
1 am exempt under Sec. . B Sa P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
1 hereby uffirm under penalty of perjury one of the following declarntions.
❑ I have and a ll maintain it Certificate of Consent o self-insure I or Workers Compare,
,cation, as provided for by Section 370 of the LnMm Cade, for the performance ref the
work for which this Permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the labor Code, for the perbonmam, tithe work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number era.
Carver: Policy Not
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ammo need not becomplctal fthe pe,,,III is boron. hundred dollars 1S 100)
in less.)
1 certify that in the Performance of the work forwhich this permit is issued, I shall
not employ any person in any manner to as to become subject to the Worker; Compere
Z. xdion Laws of California. Data
ZApplicant
.N. NOTICE TO APPLICANT: If, after making this Cerificate of Exemption, you should
a> become subject to the Worker's Compensation provisions of the Labor Cale, you must
(Ii forthwith comply with such provisions nr this permit shall b, deemed revoked.
ow Q
CONSTRUCTION LENDING AGENCY
V Q I hereby affina that hem is a conswction lending agency for the performance of
4 E~- the work for which this permit is issued (Sec. 3097, Cm C.)
0 U Lander', Sit
r U Lenders Address
I ramify that 1 have read this application and state that the above infommtion is
.F. i,i m o m
correct. I agree comply with all city and county ordinances and state laws mlating QTY.
building construction, and hereby anthorim representatives ofihis city to enter upon the
uMwe- motioned property for inspection pulawl.
(We) agree to save. indemnify end keep hurtles the City of Cupertino against
liahilides.judgmen`,,.onto expenses which toy in any way accrue ajinmox.id City
onseyypn<c 11"grpll of this petit.
Al'I'L1G 'I' U'�jly'uTy� \NDS AND WILL COMPLY WI'I'll ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will th applicant or future building occupant store or handle himmma ,material
as defined Is be Cupertino Municipal Code, Chapter 9.12, and the Haid h end Safety
Cede, Section 25532(.)'/
' ❑Yes ❑No
Will the applicant or future building oecupsm use equipment or devi rs which
tit hamrdoue air contaminants as national by the 13, Area Air Quality Management
Dlsaim7
❑Yes No
I have 4�ud the hataarr��aayyff materials reyulmments under Chapter 6.95 of the Cali -
fami.Health 8i5afet, Cu/FJS`actions 25505. 25533 and 25534. 1 understind that if the
ELECI'RICPERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP to 200 AMPS
SIGNS ELECTRICAL
RESIDENTIAL:
SPECIALCIRCUIT /MISC,
❑ SFDWL
TEMP. METER OR POLE INST.
❑ADDI'T'ION
POWER DEVICES
❑MUITI -UNIT
SWIMMING POOL ELECTRIC
OUTLETS- SWI'1CHES- FIX TORES
❑INTERIOR
NEW RE.9IDEN'I1AL ELECI'R
SO FT.
PLUMBING PERMIT
PERMIT ISSUANCE
AUfER - DRAIN do VENT - WA'I FR C,O
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, COND,
FIXTURES -PER'I'RAP
GAS - F.A. SYSTEM -1 INC. 4 OUTLETS
GAS E.A. SYS1 Jim OVER 4 IF A)
GREASE%INDUSTRL WASTE- INTERCEPTOR
GREASHTRAP
SEWER - SANITARY - STORM EA. 20 FT.
WATER HEATER W /VE.NTAiI.ECTR
WATER SYSTHMO RGTING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. P.
MECHANICAL PERMIT
PERMI'1'ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 11,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM7
EXHAUST HOOD (W/DUCI')
HEATING UNIT (TO 10,011) It'I'U)
HEATING UNIT(OVER IMAX BTU)
V17N'FILATION PAN (SINGLE RESID)
BOILER -COMP QHP OR 10,000 BTU)
BOILEER -COMP (OVER 100.11110 BTI)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, ET.
TOTAL:
OFFICE
El
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
FEE
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN REMODEL
❑ADDI'T'ION
- ❑PLUMBINGRE -PIPE;
❑MUITI -UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
[DCHIMNIiYRFPAIR
IMPIROVEMEN'1'
C] SWIM."NG POOLS
❑ BATH REMODEIIREPAIR ODEMOLII'ION
❑ GT'HER
COMMERCIAL:
El NEW BLDG /ADDITION ❑DEMOIJ PION
LaiiNANT [I FOOD SERVICE
IMPROVEMENT
VSQ, ET.
S- IV?
BUILDING DIVISION FEES
PLANCI RICK FBI;
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dam Receipt 4
BUILDING FEE
FEE SEISMIC PEE
ELECTRIC FEE
PLUMBING FEE
MECI IANICAL FHE
CONSTRUCTION TAX
HOUSING MITIGNHON FEE
PAID
Date Bectnt4.
/0" 2 % qS