30607APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY — — —
CITY OF CUPERTINO BUILDING -ELECTRICAL PERMITNO. 0 O
BUII.OINGOIVISION APPLICATIONIPERMIT PLUMBING.-MFCRANICA[.
W1 Ta'C&ig ,-vrc
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❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONRACTORIS DIiCLARATION I QTY. ELECTRIC PERMIT
I be.by affvm Nal I.. lief eed under provisions of Chapter 9 (commencing
with Seatin
ol000)of Diviosm3ofrhe Businessand Prole OwnsCode.and my licxmcoi PERMIT ISSUANCE
in full to,. and effect.
License Class Lie. M
DateContractor APPLIANCES—RESIDENTIAL
ARCHfrECTS DECLARATION PANELS
I understand my plans shall he used as public records
UPTO 200 AMPS
OWNER -BUILDER DECLARATION
a 1 hereby affirm that 1 um exempt from the Contractors License Law for the
U following reason, (Section 7031.5, Business and Professions Cade: Any city or county
which Acquires a permit to construct, alter, improve, demolish, at repair any Orucwre
prier to its issuance. also requires the applicant for such permit to file a signed statement
Nat he is licensed pursuant to the provisions of the Cuntructors License Law (Chapter 9
00 (commencing with Section 7") of Division 3 of the Business and Professions Code)or
C that he is exempt therefrom and the basis for the alleged exemption. Any violation of
ceSection 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
y not more Nan Five handled dollars M(W
❑ 1, as owner of NO Peopeny, or on, employees with wages as their sale compensation,
will do the work, and the structure is not intended or offered for sale Eme. TW4, Business
and Professions Code: The Contractor's License Use does not apply to an owner of
.. property who builds or improves thereon, and who does such work himself or through
his awn employees, Provided Nat such improvements arc not in.nded ar offered for
sale. IL however, the building or improvement is sold within Ane year ofcourpletwit he
er-builder will have the burden of proving that he did no build or improve for pur-
pose of cote..
❑ 1, as owner of the property, on exclusively contracting with licensed contractors in
eooswct the project (Sec. 20M, Business and Professions Code:) The Contractor's Li.
cease Law does not apply to on owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a enntrachans) licensed pursuant. N<Contractor's
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will mtman. a Cenifca. of Consent to self-uman, m-wemlersCampen-
.non, as provided for by Section 3IW of be Labor Code, for the performance of the
work far which this Permit is issued.
B{have and will maintain Workers Compensation Insurance, as required by Section
717A1 of the Labor Code, for the performance of the work for which this permit is issued.
Carrier:rke'eC mpensatiot Lmsu ce came,'oldY NsyyyplM
CERTIFICATE 1FEXEPTION IROM9•W70MRKERS'!�V
COMPENSATION INSURANCE
(This section need nut ed completed if the permit is for ane humlreddnllars ($100)
Or less.)
IcenBy Natinthe "brtmm¢e ofthe work for which his paten is 6med.I such
not employ any person t su t to e xn ear 'em ¢m he Workcm' Compete
O ,$ s Ginn Laws of Callifo z
7 0 Applicant r`lgl �sv c
F7 h NOTICE TO APP(. A : If,,Wer nu:mg Nis Cenillcate of F.xwnptimn, you should
a; become subject to the Worker's Compensation previsions of the Labor Code, you must
{2i forthwith comply with such previsions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
ILS k I., by which thi Nm them issued(S .ion 0OD,Cing agency for performance of
FIs the
eada's'urwhich this permit is issued (Sec.3fW7, Civ. CJ
Q U Lender's Name
04 L<nder1 Address
cerlyt
y rtie thatIhave mad this
ty and
ciunand xmtethat the above information is
to caner l agree to comply with
yannyand muntynNinarrces and state luws.laringr, QTy.
L) 2 idetengc tionad proerJ hereby euNonurposes. representatives of his city memo urymthe
above-mentioned property for inspection purpose.
(We) .,rte to save, indemnify ..it kap harmless the City of Cupertino against
lialkities.judgments, costs and expenses which may in any way uceroe vgainsI saiA City
inconsequence of the granting Of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON,POINT
SOURCE, REGULATIONS,
Signature of ApplicanVCommel Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future booking oecu uira,u re or handle haaardnus mnteNd
as defined by the Cult Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)T
❑Yea E] No
Will rhe applicant or future building Occupant use equipment or devices which
mit hazardous air concomitants es defined by the Buy Arca Air Quality Management
District?
C] yes C1No
1 have read the hemahms materials regai.ments under Chapter 6.95 of the Cali-
fomia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if Ne
building does no currently have a tenant, that it is my responsibility to notify the Occupant
of the requirements which must be mer prior to issuance of a Certifies. of Occupancy.
SIGNS ELECTRICAL
SPECIAL. CIRCUIT MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
NEW RI?SIDENTIAh EL[CfR SQ Fr.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER —DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF, AREA, COND,
FIXTURES—PERTRAP
GAS—PA. SYSTEM -1 INCA OUTLETS
GAS — EA. SYSTEM -OVER 4 (EA)
GRE"ASErINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER—SANITARY—STORM EA, 2W FE
WATER HEATER W/VENT/ELECI'R
WATER SYSTENVIREATING
WATER SERVICE
NEW RESIDENTIAL PUMP. SQ. PI'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MF.CH.
AIR HANDLING UNIT (TO 10,003 CPM)
AIR HANDLING UNIT (OVER I0,000 CFM)
EXHAUST HOOD(W/DUUn
HEATING UNIT (TO 100,0000 BTU)
HEATING UNIT (OVER 110,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER—COMP (3HP OR 100,1100 BTU)
BOILER—COMP (OVER 100,010013M)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SIL EL
OFFICE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MSCI
❑ ❑ ❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL
❑ KITCHEN REMODEL.
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEIIREPAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT FOOD SERVICE
IMPROVEMENT
❑ OMER
SQ. FT F OXtD $ISQ. rr.
OCT 2199
FEE
CII'l Ur hvul
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY ME
GRADING FEE
SOILS PF.E
PAID
Date Recolor is
TOTAL:
BUILDING FEF,
FEE SEISMICFEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL ME
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt III