S 1181APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPIiRTINO IIIA I.I)ING-ELECTRICA L FE
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BUILDING CU ERTIN APPLICATION/PERMIT PLUMBING - MECIIANICAL S 1181
BUILDING PROJECTIDENI'IFIL'A'DON i 1
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❑ Consultant Fees Paid by Applicant (initial)
I hereby aRrm that 1 am licensed under provisions of Chapter 9 (commencing
QRZ with Scnimn 11X0))af Division3 rel the Rusincss vnd Pmfessinm Calc. vnA my licemeis
t W . intuit face and effect.
I: gene CC�/%.{]�� I,ic.a
NQa uta- s ��sF Cm lolaol
Oy 4/ ARCHpI iCI"S DECL RATION
G Ivndacaanduay plansshall he used n.spublicrecoNs
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N W Licensed Professional
OWNER -BUILDER DECLARATION
tY W Q I hereby affimc that I am exempt from the Conformities License Law for the �6U following reason. (Section 9031.5, Business and Professions Could Any city or county
LL O which requires a permit to concoct, alter, improve, demolish, or repair any structure
prior ill its issuance. also requires the applicant for such permit to file a signed statement
� y that he is I acarsed pursuant to the provisions of the Contrdc roes Licence Lnw I..... 9
(SCO (commencing with Section 7") of Ili vision 3afthe Business and Profusions Cale) or
aa thea he is exempt Therefrdn and Thu basis for the vllegad exemptlnn. Nry vinl1 at of
oN Section 711315 by any applicant for a permil subjects the applienm Ina civil penally Or
2q
on marc Oran five hundmd dollar, S508).
2l) I, vs owner of the pnapnny, or ley cmpinyces with wages ns their sole unnlnnamion,
p., will do the work, and the animator, is not imcndedor offered forsale Nec.A044. Buttress,
Wvnd Pmo signs Code: The Contractors License Law deo not apply to ua Owner of
0. pmPerty, who builds or imprmes thereon, end eche does such work him,ch nr (trough
his own employee,, provided that such improvements are not intended or offered for
sale. IL hmvsva, 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 nr improve for for,
paw of svled.
I, as owner of the prapeny, ate exclusively contracting with licensed contracmm to
construct the Project (Sec. 1034, Business and Prufe it ns Code:) I [Fr C mmdnr's Li -
cow Low dues not apply to an ow tier or property who builds nr lnrprvves l hemnn,and QTY,
wlwc mraU, lar such Pr it Iti wilt a cnnmamge) li twilled Pollution, he C Ono Mnr's
License Law.
❑ I am exempt under Sec. ,I3&1'C lin this rcaum
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury, one of the following declarutions:
❑ I have and will maintain a Certificate of Cnmentto self-imm. for Wn m,'sCompen-
union, as provided far by Section 3103 of the Lahr Code , for the performance of the
work far which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, its required by Section
TEXT of the Labor Code, for The performance of the work for which this permit is issued,
My Worker's Compensmimi Inxmmsce earlier and Policy number mm:
Currier: Policy No.'.
CERTIFICATE OP EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need not he canplmrd ifthepermit is far one hundred dollars ($IM)
or Ices)
1 cmify that in the perfonmanec oDhe wank fontshich this permit is issued.I shall
sol employ any person in any manner an as to became subjecran the Wmikeri Conan
HLECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RIS I DENTIAL
PANELS
HIT IT 200 AMPS
SIGNS ELECT RICAL
SPECIAL CIRCUIT/MISC,
TEME METER OR POLE INS .
POWER DHVICES
SWIMMING 11001. ELECTRIC O .�
OUTLE'I:S-SWITCHES-PIXTURES
NEW RESIDENTIAL ELECIR SQ IT,
w�-c V2 NOTICE TO APPLICANT"l?. uBer making this Certificate of Exemption, you should
F^ bmnne subject to the Workers Cumpenswinn Provisions of the Labor Code, an must
Fa2.lQforthwith comply with such provisions nr(his permit shall be deemed meukcd.
as CONSTRUCTION LENDING AGENCY
U 1 hereby affirm that there is a con0mninn lending agency for the pedonnunce of
W — the walk for which This pronal is issued (Sec. 3091, Civ. C.)
0 U larder's Name
IandeJs Address
1 I certify thm I have read This application and state Rod The above information is
N torten. I agree to comply with all city and county ordinances and stale laws relating to QTY,
V Z building construction, and hereby authorize representatives ofthis city to enter upon the
above-mentioned property for inspection purposes
(We) agree to s...aaa���ffffffe, indemnify and keep hamdess the City of Coleman against
livhilities,judgments�ts multipart which may in any way meme against said City'
' yyuuenca of the ,an, gofT Pendt.
A a ';ANTJIND RSTAND. ND WILL COMPLY WITH ALL NON POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant some or handle havmJnus material
as definW by the Cupertino Municipal CMe, Chapter 9.12, and the Health and Safety
CMe. Section 25532fa)^
[D Yea 0 N
Will the applicam for furor, building accnpunl use epepmmol it, devices which
omll hnwrdoes air eo earrummtx rex delin d by the Ray Area Air Qual by Management
District?
❑Yes ❑NO
1 have read the huuNous mu¢riaN requirements under Chapter fs95 of the Calk
Tornio Health & Safely Code. Sdtions 25505, 25533 and 25534.1 undemmnd that if the
building does not currently have a mount, that it is my responsibility m notify the executed
of the muf iremen8 which must he film prim to issuance of a Certificate of Occupancy.
Owner or automated agent Dora
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - GRAIN & VENT- WATER (EA)
RACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, RODF AREA, CONI),
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - HA. SYS "I EM -OVER 4 CA)
GRHASIYINDUSI'RL WASTE INTERCHIPI OR
GREASE TRAP
SIiWIiR- SANITARY -STORM EA. 2001 IT,
WATER HEAT17R WIVENT/ELECI'R
WATER SYSI EM/I REATING
WAI'Ek SI iIdV ICE
NEW US IDEN I I AI. PLMB. SQ. PI'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
AIR I[AN DIJNO U NIT G 010,00) CFM(
AIR HANDLING UNIT (OVER 10J00 CPM(
EXHAUST HOOD(WfDUCT)
BEAT] NO UNIT (TO 100.000 BTU)
BEAT ING UNIT (OVER 100,000 ETU)
VENTILATION PAN (SINGLE RESID)
BOILIiR -COMP (311P OR 110,800 IT'I'U)
8011.138 - COMP (OVER 100,000 It I Of
AIR COND I'TONER
NEW RESIDENTIAL MECH. SQ. FT
I OFFICE
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❑
BUILDING PERMIT INFO
_
BLDG ELECT PLUMB MICH
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI, ❑ KI'ICHIiN REMODEL
❑ADDITION ❑PLUMBING RH-PIPE
❑ MUM bIJNI'1❑STRUC'1'HEAT,
MODIFICATION
❑ TNT ERIOR [I CHIMNEY REPAIR
IMI'ROVHMENT E]SWIMMING POOLS
❑ RA'I'I I RENIODFUREPAIR ❑ DHMOIJ I ION
❑ OI'iIER
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑DEmou DUN
ElENANT ❑F)ODSER ci;
IMPROVEM�9� A` nom,
❑ )TIER
„.Ali)
EEE AN 27
coyr,fk. �
FEE
BUILDING DIVISION fH1?S
PLANCHECK FEE
ENERGY PIT!
GRADING FEE
SOILS PEE
PAID
DF,
(BUILDING
I HOUSING MITTQATION FEE I
PAID
Dole
WSQ. Ff.