29210APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION _ APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRESS: -
1 hereby affirm that 1 am licensed under, provisions of Chapter 9 (commencing
widt Seem. 9000)af Dammion 3ofthc Business and Professions CodL and my l iwme is
In Po11 force and effeoLI�
LIyaXCknew L,( Lic.p
4r;) ., CvPeno , CJA
'ON 'I'It OTT RS NAME I CNO:
DDS:
/ Q /P I(��l Ceti- R`iQ_
PEEK, CA 6-D05 ❑ Consultant Fets Paid by Applicant (Initial)
ITY. ELECTRIC PERMIT I FEE
Z b N Z 1 understood my, plans shall be used ax public recmds
OZ4
LicenxedPorne"amed-
OWNER-BUILDER DECLARATION
1 hereby union that I am exempt from the Contractor's License Law for the
ip5, d U following reason. (Section 703 1.5. tininess and Professions Code: Any city or county
F LL O y which requires a permit to construct. alter, impmve, demolish, or repair any pmdum
q� prior to its issuance, also requires the applic.nt for such pemaitto file a signed statement
yyWWy that he is licensed mr,reat to the most sionsof,ha Commoon'a Liatnso Law (Chapter 9
Cad (commencing with Section 1000) of Division 3 of the Business and Professions Code,m
that he is exempt Ihcrtmm and the basis for Nc alleged exemption. Any violation of
LiVC {L
Section 9031.5 by any applicant for a pennn subjects the applicant n a civil penalty of
I- Z} not more than five hundred dollars (SSW).
56 ❑I, as ownerofthe pmpeny, or my employees with wages as their sole compensation,
F
will do the work, a ud the soucture is not imusica nr offered for sale (Sm.7(144, Business
and Professions Cade: The C es Cher rs License law saes ten apply er ifo owner of
6'3 � property who builds or improves Ihcreon, and who dos such wink himulf nr through
his own employees, provided thin such improvements are not intm4icd car offered for
sale. IL however, the building or improvement is sold within one year of completion, the
owner - builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contmcters to
consumer the project (Sec. 7644, Business and Professions Code) The Contractor's Li.
cense law does not apply to an owner of property who builds or impmves thereon, and QTY.
who contracts for such projects with a co anictur(s) licensed personal to the Conicfur's
License law.
/ ❑ 1 am exempt trader Sec. , B & P C for this reason
Date
WORKF,R'S COMPENSATION DECLARATION
I hereby effitm under penalty of perjury one of Nr following Jcdamtions
] I hove and will maimein a Crnificam ofConsem m ulDinsure f n Worker's Compen-
aminn ns pmvided for by Section 3744 of the Lahr Cwle, for the perfonnuncc oT the
work for which This pennn is isweA.
❑ 1 have aM will Ittainmin Workers Compensation Insumna, a mlmired by Sermon
l7 tithe Luton Cale,lm"he perfnrmancenf the work forwhich cis permit iai suet.
N'mrke�ymf<nxuli ➢lysprpngycarticr anJ Policy puryhe(am: a . � D 7A.
COMPENSATION INSURANCE
allossectiot overarm, be completed iflhe permit is fnrone hundleddollun(SIWI
of less.)
I certify that In the perforntunce of the work Lin which this permit is ixeucQ 1 shall
not employ any person in any manner so as to become subject to the Worker' Compcn-
O Z cation Laws of Coldcana.. Date
z Q Applicant
y NOTICE TO APPLICANT. If, after making this Croatian, of Exemption, you should
a become subject to the Worker's Compensation provisions of the I.aMn Code, you must
forthwith comply with such provisions or Ibis permit alto)) he deemed revoked,
Z) z CONSTRUCTION aLENDINGAGF.NCY
IL t7 I f r which erMm is sued (Sec. 0 7. Civg agency fnnhc performance of are F Under'k for which ibis permit is issued )Sec. 3097, Civ. CJ
ULender's Name
LenAer'sAddmna
1 certify that 1 have r.it this opplirtaim and state that the abawe remittance ce is
V1 correct, l agree to comply with all city and county ordinances and state laws relating In QTY
U building construction, and trashy authnrire representatives of this city or enter upon the
abovcmentionea propeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupcnin0 again"
liabilities, ju lloomis, costs and expenses which may in any wary creme ogaineI said City
in consequence of the standing of this permit.
APPLICANT l f7rf:JDS AND WIL1llQRB7Q' WITH JLL NON /'OINyS
HAZARDOUS MATERIALS DISCLOSUR7!
Will the applicant or future building occupant store or handle hinummua material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safely
Cotta Section 25532(.)?
❑Yea ❑No'
Will are applarm or future building occupant use equipment or devieee which
•nail by adous air cmnlammunts us defined by the Bay Area Air Quality Management
)IAlrlC17
❑Yes El No
I have lead the hacmdous nmmrlals requirements under Chapter 6.95 of the Cal i -
forms Hula, & Safety Code, Sections 25585, 25533 and 25534.1 underandal that if the
building does not currently have a tenant, that it is my msponsibility to notify the occupant
of the requirement which must he met prior to issuance of a Cufforme of Occupancy.
Owner or aulhmnied agent Dale
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UPT02MAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
'TEMP. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - S W ITCHIN - FESTERES
NEW RESIDENTIAL ELECTS SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
AI.TER -DRAIN & VENT- WATER (EA
HACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, COND.
VIX'1'U R Its -PHR TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4IRA)
GREASIJINDUSTRL WASTE IM'ERCHMOR
GREASETRAP
SEWER- SANITARY -STORM IiA. 200 FT.
WATER HEATER WNENT/ELECPR
WATER SYSTBM/IREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FIE
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
AIR HANDLING UNIT (10 Mason CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
HEATING UNIT (TO 100.000 BTU)
ABATING UNIT (OVER 1011,100 BTU)
VENTILATION FAN (SINGLE RESEH
BOILER -COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL NIECE. SQ, ET.
OFFICE
JOB DESCRIPTION
29210
NITARYNO.
APPUCATIONSUIIMIT3'ALDATF.
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
-k S^_C(�
NIC
MODIFICATION
gftTROL M
❑ CHIMN17Y REPAIR
IMPROVEMENT
SQ, Up. FLOOR AREA
❑ BATH REMODEL/REPAIR ❑DEMOLITION
BUILDING P .RMIT INFO
3LDG
LX P A1V.CIL
El'
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
11 STRUCTURAL
MODIFICATION
❑INTERIOR
❑ CHIMN17Y REPAIR
IMPROVEMENT
SQ, Up. FLOOR AREA
❑ BATH REMODEL/REPAIR ❑DEMOLITION
[]OTHER
3 P8I
COMMERCIAL:
EW BLDG /ADDITION
❑DEMOLITION
I❑ hNANT
❑FOODSHRVICE
MPROVEMENT
❑ OTHER
SQ, Up. FLOOR AREA
$ /SQ. 14.
3 P8I
1AM 18 1ggR
E�rr-
STORIHA TYPECONSTRUC ION
OCCGROUP APN
BUILDING DIVISIO 'E 13S
PLANCHECK FEE
ENERGY FEE
GRADING FEE -
SOILS FEE
PAIU
Racipt k
TOTAL:
BUILDING PEG IS r�
SEISMIC FEE
ELECTRIC FE/
PLUMBING 1E -
MECHANIC LFEE
CONSTRUCI'10 X
(LOUSING MITIGATIO F.13
PAIU
Uale Rc¢d M