30223APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOF FRTINO BUILDING - ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT -oo. PLUMB IN6c MECHANICAL. , 30223
00110R1
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby ifllnm that I .,it licensed under provisions of Chaper 9 (cnmmeneing
with Section 7") of Division 311 Btemessand Frofessions Coda, and my licen.m is
in full force and effect,
Lmmyc Class Lic. g
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
OWNER -BUILDER DECLARATION
I hereby effort that 1 am exempt from the Commemex License Law for the
following reason. (Sachet 9031.5. Business and Professions Code: Any city or county
which requires a permit m construct, che, improve, demolish, or repair any stmcmre
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant m the provisions of he Commcmr's License Law (Chapter 9
(commencing with Section 70010) of Division 3 of the Business and Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption, Any vitiation of
Section 9031.5 by any applicant for a Permit subjects Ne applicant m a civil penalty of
not mom thin five hundred dollars ($5110).
❑ I,as oivar,i the property. or my employees with wagesasthair sale compensation,
will do the work, and the structure is not intended or offered for sola (Sec. 7044, Business
and Professions Code: The Contractor's License law does not apply man owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one yearofec mpledon, the
owner -builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
❑ I, as owner oI the prupeny, um axclusively emit noir, whb Inva,,rd conwmrns to
construct the projret (Sec. 7044, Business and Professions Code) The Contractors Li-
sa Law docs not apply to an owner of Property who builds or improves thereon, and QTY,
whoconwcts for such projects with a conmacmr(O licensed pursuant to the Cnnvucmr's
License law.
❑ 1 am exempt under Sec. . B & P C fur this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hcraby from under penalty of perjury one of the following feel arulours:
❑ Ihav and will maintain a Cinifirma ofCimmin msel6mmirm for WnrkersCompen-
sation, as provided for by Seel ion PW of the Labor (bade, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37W of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No :
CERTIFICATE OF RXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is forone hundred dollars ($100)
loss.)
1 certify that in the perfamtance of Ne work forwhich this permit is issuod, l shall
not employ any person in any manner so as to became subject to the Worker..' Cmmpan-
union laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Certificum of Exemption, you should
become subject m the Wmkers Compensation provisions of the Labor Cade, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONST RUCTION LENDING AGENCY
I hereby affirm ohm there is a mann ction lending agency for the perfume nce of
the work for which this permit is issued (Sec, 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and sum laws relating to QTY,
building confirmation, and hereby auhorim mptescnmtivcs of this city to ewer upon the
above-mentioned prepeny for inspection purposes.
(We) agree to save, indcmni fy and keep hurmlees the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE. REGULATIONS.
Signature of Ap,1a,auJCommi Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant suite or handle h tomdons material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cale, Section 255321x1!
❑Yes MN.
Will the applicant or luwra building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes C] No
I have mad the harardous materials requimments under Chapter 695 of the Cali
forma Heal b & Safety Code, Sections 25505, 25533 and 25534. 1 understand that If the
building does not currently have a mnam, that it is my responsibility to notify the occupied
of the requirements which must be met prior to issuance of Certificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE.
APPLIANCES -RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SQ FT.
PLUMBING
PERMIT ISSUANCE -
ALTER - GRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC.4 OUT LIUX
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRLWASTE INTHRCCPrOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 IT.
WATER HEATER W/VENT/ELECfR
WATER SYSTEMITREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. rL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IQ000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RfSID)
BOILER -COMP (3HP OR I W.(If10 BTU)
BOILER -COMP (OVER 100,0(10 BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. FT.
OFFICE
❑ C)t -
BUILDING PERMIT INFO
BLDG
DGG ELECT PLUMB MECH
f� A_ E
FEE JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELIREPAIR []DEMOLITION
❑OTHER
FEE
❑ WBLDG/ADDITION ❑DEMOLITION
ANT ❑ FOOD SERVICE
I IMPROVE
❑OTHER
SQ. FT. FLOOR AREA I $/SQ. FT.
STORIES
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Rerem,N
TOTAL
BUILDING FEE
FEE SEISMIC FEE
ELECfRICFEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dam Receipt)
TOTAL:
ISSUANCE DATE