30889APPLICANT TO FILL IN INFORMATION WITHIN RED
USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL. renMU NO.
BUILDING DIVISION APPIACATION/PERMIT I PLUMBING - MECHANICAL' 30889
CONTACT:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm mnt I I licensed under prosvieians of Chapter 9 (mmmcncing
with Seclim1700 Divizi p31,filbeBusurasixioul ProfcaxonsCodnandmy license is
in fall force and effect.
License s Lie.X
DaleContractor
A.,,H iC'S DECLARATION
1 understand my plans shall b, used as public mcods -
tar ra MCC, &C
❑ Consultant Fees Paid.by Applicant (Initial)
ITY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200 AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I um exempt from the Contractor's License Law for the
following reason (Swoon 703 1.5. Business and Professions Code: Any city or county
which reclaims a permit in consuuct, alter, improve, demNiah, or repair any structure
prior to its issuance, also requires the applicant for such .am file a signed slalcmcnt
that he is licensed pursuant to the pmvisions of the Contmemrs License Low (Chapter 9
(commencing with Section 700() of Division 3 of the Business and Professions Codi) or
that he is exempt therefmm and the basis for the alleged exemption. Any violation of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mow than five hundred dollars (S500).
❑ I, as owner of the propun,, or my employees with wages as their sole compensation,
will an, the work, rand the xbucmre is not intended or aRcred for snle (Sec. 1014, Business
and Pmfessions Code: the Contractor's License law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided than such improvements are not intended or offered fir
sale. If. however, 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 or improve for par,
pna of talc.).
❑ 1, res owner of the property, am exclusively convecting with licensed commctors no
consumer the project (Sec. 1044. Business and Parfessiona Code) The Cmnmcun's Li.
cense Law does not apply to an owner of property who builds or inn mvcs action, and QTY
who convects for such project with a sac rocoad%) licensed Pursuant to the ContraI
License Law.
❑ I am exempt under Sec. ,11& P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby ammo under penalty of perjury one of the following declarations:
❑ I have and will maintain a CertificateofConsenuasclf-insurefnrWorkersCnmpen-
sation, as provided for by Section 3100 of the Labor Code, for the performance of the
work for which this permit is issued.
-7 1 have and will maintain Worker's Compensation Insurance, us required by Section
31 W of the labry Cahc-for the performance o(the work fur whi h mhis pcmi t in issued.
Carr erMy r fits stall s non eriond Poll,,
Policy No.:
CERTIFICATEOF XEMP1ONIROMWO11KERS'
COMPENSATION INSURANCE
Gbit swuion need not be completed Film Norman is forma, hundrnl dollars ($KaB
or Icss.)
I certify that in the perfonrunce ofthe work for which this Knout is issued, I shall
not enoploy any Pei son in any manner so as m become subject o the WorkersCompe to
O Z satimn Lawsaf Califomia. Data
7 0 Applicant
%t NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the LAmr Code, you roust
[a21 Q forthwith comply with such pon,uncnsormis Permit sial l he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
fJ C Iherehy affirm that there is a construction lending agency for the performance of
W H the work for which this permit is issued (Sec. 3197, Civ. C.)
O U Lenders Name
W Lenders Address
pt I cenity that I have read this application end state that Use above information is
y career, I agree to comply with all city and county ordinances and state laws relining to QTY,
building construction, and hereby authorize representatives of do,61y,, enter upintho
above-mentioned property for inspection purposes.
(We) agme to save, indemnify and keep hartnless the City of Cupertiagainst
ro
liabilities,judgments,costsandexpenses hic
ohmayin any way accrue ogainssmidno City
innsequenecofthe granting ofthit.
APPLICANT UNDERSTANDS [LI, COMPLY WITH ALL NON -POINT
Willthe apph m or future building occupant store or handle hazardous material
ande by Ne Parma Municipal Code, Chapter 9.12, and the Health and Safes.
Code, Section 2 .2(a)?
❑Yes - E] No
Will the applicant or future building meapant use equipment or devices which
emit hazardous air contamiwnts as defined by the Bay Area Air Quality Mism,ph vent
District?
❑Yes 7 N
I have rend the awardous materials requirements under Chapter 6.95 mf the Cali.
fundsHealth & Safety Code, Sections 25505, 25533 and 25534.1 understand thin if the
hnildl ng does not correctly have a mown, shut it is my msponslhiiny moody the occupant
of the requirements which most be met prim m iuuanee of a Certificate of Occupancy.
Owner or authorized agent pate
SIGNS ELECTRICAL
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLEI:S - SWI rCIIES - FIXTURES
NEW RESIDENTIAL ELECTS SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
RACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, CON U.
FIXTURES -PER TRAP
GAS -EA. SYSTEM.I INC.4 OUTLET
GAS -EA. SYSTEM -OVER 4 (EA)
GREASHIINDUSTRL WASTE 1'ERCEPTOR
GREASETRAP
SEWER -SANITARY STORM HA. 200 PT.
WATER HEATS NCNT/ELECTR
WATER SYS MTREATING
WAfER iRVICE
NE RESIDENTIAL PWB. SQ,IT.
MECHANICAL PERMIT
PERMIT ISSUANCE.
ALTER OR ADDTO MECH.
AIR HANDLING UNIT(TO 10,000C )
AIR HANDLING UNIT (OVER ,fAMI Cf
EXHAUST HOOD (W/DU
HEATING UNIT (ID ,BN) BTU)
HEATING UNIT ER Forfon B'ru)
VENTILATE FAN (SINGLE RESID)
BOILER COMP(HIP OR 1011,0011 BTU)
BOLI -R-COMP(OVER 100,000 BTU)'
OFFICE
X
BUILDING PERMIT INPO
❑ ❑
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MOD1171CATION
TERIOR
El CHIMNEY REPAIR
IMPROVEMENT
HOUSINGMITIGATI NFEE
❑ BATH REMOD • E II
DEM ATION
❑OT ER
PAID
s
Doc Ki p
TOTAL:
COMMERCIAL:
11 NEW BLDG/ADDITION
11 DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
-
❑OTHER
SQ. FT. FLOOR AREA I S/SQ. FT.
Pill
FEE
Piga &rev
5_ur %ALUA
STORIES
OCC. GROUP
BUILDING DR
PLANCHECK FEE
ENERGY FEE
HEADING FEE
SOILS SITE
PAID - _
FEE
BUILDING HE
SEISMI"EEL
ELECTPLUMBMECHd)CONST
HOUSINGMITIGATI NFEE
PAID
Doc Ki p
TOTAL:
ISSUANCE DATE
ISSUED BY: 1
SQ. PI.
TOTAL: