99090097APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING - FLECTR
BuamNCD VISION APPLICATIONIPERMIT PLUMBING - MECHAI
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ADDRESS:
F-1 Consultant Fees Paid by Applicant (Initial)
LICENSED CIN I FACTOR'S DECLARATION QTY.
1 hereby alRnn that I am licensed under provisions of Chapter 9 (commencing
full
]pOp)nf DivisionJofNe Business and Professions Cale, and mylicense is
in full a Class
and elTcct.
DataClass Co.LicM
Date Cotractor
AFC TS DECLARATION
1 untlersrad my nplans shallall be he used as public records
Lumasal Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt front the Contractor's License Law for the
following reason. (Saction ]OJ I.S. Business and Professions Code: Any city or county
which res vires armit to construct clout, improve, demolish c stru
@ IDm . r repair any tare
power, its issuance, also ve,mac,the Ne applicant for sash permit to Glu n signed (Chapters) em
that heislicensed pursuant mtheedDiviomof the Contmctco License Low ICM1apr) 9
thammene xewith Section ](X10) of Division S th the Business pt Pro Anyvio Gde) nr
that io is 31.5 b therefrom and Ne hods for the allege) exemption. Any violation of
Section JOhim by any dredd ][ ($500).
P-812",
suM1jxrs the applicant to acivil Penalty of
not tye(elhne five hundred dollws I empl.
av owner of the pmpeny, or my employees with wages as their sole compensation,
will dothe work, ands: heContisnotintendedc Law door salepply]014, Business
and Peaany who
Code: The Contractors floc
or's Crouton Law does not apply to if owner of
his o ny who builds or improves thereon, and who does such work himself or through
his own employeesbuilding that such improvements thin not intended or oBercd for
sole If• how ver, the
building or improvement is sold within one year of completion, the
nw
ner-huilaer will have the burden of proving that he did not huilA or improve for par-
'. m
oo(roseo sole).
co a
I, as r of ct property, , B exclusively confessions with licensed rnntmanrs i-
cense La the es not p x. ]IW4• Business ro rty who ons
Cosda&ori proUn, Contractor's rid
Li-
cense Law Jces not apply m an owner of property who huilN or improves thereat, end QTY
who contracts formch pm wiNa/S onfeoctnr(s) licensed pumuanr to the Contractors
License Law.
D lam eacmpt ua" ,a / ,B&PC fO this mu9m
WORKER'S COMPENSATION DECLARATION z z - I
1
hereby.
ffirm under penalty of perjury one of the following decimations:
❑ I have and will maintain a Certificate wConsent to self-insweforWorkereCompen-
sation, as provided for by Section 37W of the Labor Code, for the performance of the
work for which this permit is issued.
O 1 have and will maintain Workers Compensation Insurance, as required by Section
97110 o1 be Lab or Code, for the pvo nionecofthe work for which this permit is issued.
My Workers Compensation Insurance cancer and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seewn needrwl be completed if the permit is rorone hundred dollars (SIM)
or less.)
1 cenify that in the Performance of the work for which this pemtit is issued, I shall
noson r employ any perin any manner so as to become subject e subjeco the Workers' Compen.
zit
Laws of Califomia. Dam
z O Applicant
y NOTICE TO APPLICANT: IL after making this Cenificme of Exemption, you should
a , become subject to the Workers Compensation previsions of be Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
z
CONSTRUCTION LENDING ngagerAGENCY
Us l far
reby whichina thatennui isand(Ser. 30 lending agency for [be performance of
0 H the work for which Nis permit is issued (Sec. 3097, Civ. C.)
Q W Larders Name
6tl1 Lenders Address
t 1 certify that I have read thirty ad real and sat¢ that the above information is
Z coma. I agree to comply wish all city and county ordinances and store laws relating a QTY.
V 2 above-melifing ntioned
hereby amtionurposes. utiles of this city mentor upon the
vhnve-mentioned t o save for inspection purposes.
( judgments,
agree to save, indemnify and keep harmless the City of Cupensts against
liabilities,judgments, cos¢ and expenses which may in any way accme against said City
in cnnscyucn he gr ting of Nis µanis.
APPLIC E TANDS AND WILL COMPLY WITH ALL ON- OINT
SGDR . N5� 9�r�q
I IAZARDOUS MATERIALS DISCLOSURE '
Will the applicem or future building occupant store orhandle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Coda Section 25532(x)]
' ❑Yes ONs
Will the applicant or future building occupant ma, cyiii, mentor devices which
nail hazardous air comamimms as deined by the Bay Area Air Qm1n, Management
Diadem
❑Yes ONo
I have read the h s materia' requirements under Chapter 6.95 of Ne Cali-
fomia H II ofery C e, Sections 25505. 25533 and 25534.1 andy� land�jat if Ne
huildin yh�uvexmrwn6 that it is myresponsihii ay�Jj}+us'fy� titJ� pant
of the tyles J{eCatPe meypria m issuance of a Ccy7ififJ 6hdd-.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02MAMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIJ]MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF, AREA, FOND.
FIXTURES-PERTRAP
GAS - EA. Sys TEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM-OVER4 (EA)
GREASEdNDUSTRL WASTE INTERCEPTOR
GREASETRAP SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WNENDELECTR
WATER SYSTEM"EREATING
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ, ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,0110 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WMUCT)
HEATING UNIT(TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR INL000 BTU)
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. F..
OFFICE
FEE
a
❑ LJ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
D SFDWL
D KITCHEN REMODEL
DADDITION
CIPLUMBING RE -PIPE
D MULTI -UNIT
CSTRUCTURAL
MODIFICATION
D INTERIOR
ElCHIMNEY REPAIR
IMPROVEMENT
[ISWIMMING POOLS
D BATH REMODELIREPAIR
CDEMOLITION
D OTHER
C
tea nr
L
COMMERCIAL:
ONEWBLDG/ADDITION
ODEMOLrrION
13TENANT
11FOOD SERVICE
IMPROVEMENT
OOTHER
FEET --i 11-1 SEP 15
Irira:llel
qP 03
BUILDING DIVISION FEES
PLANCHECKFEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
BUILDING FEESS
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEC
MECHANICAL FEE
CONSTRUCTION X
HOUSING MITIGATION
PAID
Data
TOTAL'
ISSUANCE DATE
ISSUED BY: