29800APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT N0. (� (] O O O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL. LJo
V 14 P-4-V/S4
re,,/4 NCS RSS z,00 -o
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirte tem I am licensed under provisions of Chapter 9 (commencing
with Seclam ]1100) ofDwision 3 ofthe Business had Professions Code, and my license is
in full force and effect.
License Class Lit,N
❑ Consultant Fees Paid by Applicant (Initial)
y ARCHITECPS DECLARATION
7J. 1 understand my plans shall he used as public records
ail Licensed Professional
[4j OWNER -BUILDER DECLARATION
Q I hereby affirm Nat 1 am exempt tram the Contractor's License law for Ne
following remelt. (Section 7031.5. 9usineas and Profusions Code: Any city or county
which requires o permit to construct, alter, import e, demolish, or repair any structure
Prior to in issuance, also requires the .,pi cow, for such penuitto file a signed statement
that hens licensed pursuant to the provisions of the Commcmr's License Law (Chapter 9
C (cmm�mncing with Sco too 700a)) of DM,,ort 3 of the Business and Professions Cele) or
e' that he is exempt therefrom and the basis fur Ne alleged exemption. Any violation of
or Section 7111,11, any applicam for a permit subjects the applicant to u civil penalty of
y
warrants, than five hundred dollars ($500).
C the
worotrhe property,Ur mycmployces mothered!
ofor sale
04m1,B Business will dmhewmr6, andthestmcwmisnot Pntendede Case it forsale(Sec.. so Business
and I ,rapers,
he
b Code: The thcmr'a License law does amt apply s an owner of
.. his o ny who builds or improves t t such i, and who does such sink himself or Nrou or
his awn employees, provided that such improvements are not intended or altered for
sale. r- however, Ne building or en of moving
it raid within one year of completion, the
owner -builder will have the burden of proving rho he dna not build or improve for put-
1,usowner oject property, am at acts and
and contracting with IlcunseCnnnuaoan to
Warner the project(Sec.o an Businessrope Professions Cnda)The es the tar's std
whocamse Lpwdoes not tsforschplytoan with
awner ofprnpens who
sedpurimpmves Ncreunuwd QTY,
who contracts for such projects with a comracmHs) licensed pursmnr m the Commnara
1 nm exempt under Sec
B & P C for this rcmon
(Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby offirn under penalty of perjury ane of the following declarations:
❑ I have and will maintain a Cenificute ofConsem to self -insure for Wmker's Camper -
action, as provided for by Section 3700 of the Lal nr Coca, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3]I10of the l.e Code,for the Performance of the work for which this permit is issued.
_JMy Work mNn. Incur e r and Policy number are:
Cnriec Paltry No.:
CERTIFICA EOFI EMPTION FROM WORKERS'
COMPIi 'ATION INSURANCE
(This section need not be completed if Ne permit is (erose hundred dollars Olo0)
or less.)
I ramify that in the perOmnance ofthe work for which this permit is issued, l shall
not employ any person in any manner tons it become subject to rhe Wnrkcw' Campen
z nation Lawsof Chifmnm Date
7 O Applicant
�T IA NOTICE TO APPLICANT: If, arm, making this Certificate of Hxemp ran. you sbauld
become subject to the Workers Compensation previsions of the "her Code, you must
Forthwith comply with such provisions or this permit shall be deemed revoked,
aQ
0 CONSTRUCcIONLENDINGAGENCV
U
V Q k herebyaffirmhiNhuhere iso ad(Sea 0lending agency for Performance of
114 H the work for which his permit is issued (Sec. l09], Civ. C.)
L) Lender's Nome
W LendelI Addressi4 I certify that 1 have read this rpplicntiun and nam That the utxwe information is
W correct. l agree to comply with all city anti county ordinances and state laws reining m qIT.
V ZhuilJing amswction, and hereby mahodre represenmrivesoflhis city menterupun the
above-mentioned phi for inspection purposes.
(We) ngme to save, indemnity and Peep harmless the City of Cuperino against
Hi bilitiea,judgments, casts and expenses which may in any say .cane against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
SOURCFj� 1.ATION.S.
- HAZARDOUS MATOUALS DISCLOSURE
Will the applicant or Dame hnlldi all hecupant store or handle hammous mnmrial
as darned by the Cupertino Municipal Code, Chapter 9.12, and the Ilcalth and Safety
Crede, Section 25532(a)'!
❑Yes ONo
Will the applicator or furore building occupant use equiprnenr o devices which
emit hazmdaus air contaminants as defined by the Bay Area Air Quality Management
District?
El yet, ONo
1 have read the hazardous materials requirements under, Chapter fi 95 of the Cali-
1'amia Health & Safety Cole. Seances 25505, 2,5533 and 25534. 1 understand that if the
huilding does not currently haven tenm9, Nut h k sty neptmul ihly he unity the occupant
of the aquitemerm which must he met prior to issuance of a Ccrificum of Occupancy.
Owner or authorized agent Date
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPT02W AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW rSIDENTIAL ELECTR
ALTER-7)Rily & VEM'—
ROOF. AREA, COND.
FIXTURES — PER T
GAS—EA. SYSTEN;- I IN . UT
GAS —EA.SY VER4(EA)
GRHASFANDUSTRL
GREASH-TvAP
NEW
SQ IT.
SANITARY—STORM FA.2001'T.
PERMIT ISSUANCE
ALTER OR ADD'f0 MECH.
6
N
JOB DESCRIPTION
RESIDENTIAL -
ESIDENTIAL-OSFDWL
El SFDWL
O KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
O INTERIOR
OCHIMNEY REPAIR
IMPROVEMENT
O BATH REMODEUREPAIR ODEMOLITION
OOTHER
COMMERCIAL,
G NEW BLDG/ADDITION El DEMOLITION
0 TENANT 0 FOOD SERVICE
IMPROVEMENT
GOTHER rV06, 90009.;; L_`A
SQ. FE FLOOR AREAtF—
FEE
F'1
NOl9l� VALUATION , r
TYPECONSTRUCTION
_r r��nluvu
FEES
4PAID
DING FEF/
LS HE
DOm eIpIjso.�.
TOTAL:
DING FEE en MIC FEECTRIC FEE
MBING FEE
AIR HANDLING UNIT GO 10,000 CFM)
AIR HANDLING UNIT (OVER.100g) CFM)
EXHAUST 11001) (W/DUCT)
HEATING UNIT TO IOO,OW BI U)
HEATING UNIT (OVER I W,WB BTU)
VENTILATION FAN (SINGLE RESID)
BOILER —COMP BRP OR IBO,OM BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RIEEDENIIALMECH. SQ. IT.
OFFICE
I MECHANICAL FEE I D/,GWQ I
I CONSTRUCTION TAX I I
I HOUSING MITIGATION FEE I I
PAID
Data Receipt
TOTAL:
ISSUANCE DATE