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CITY OF CUPERTINO BUILD INO-ELECTRICAL PERMTTNO. P]OH!..//�V
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
CZp with Snmimn]0o(B nfl3ivisionJaf the pusiness nnA i'ndesvinns 6sdc, and Tny license is
in full farce end effuLC O !r O 1
Z se less J b Catnap T wcurr Toll Val FIrs/p4ci.
F -G y ARCHITECTS DECLARATION
'A O t2 4 1 understand at, plans shell heated as public ruconls
OZ—
; Licensed Professional
y-4 OWNER- BUILDER DECLARATION
C 6 I hereby affirm that I em exempt from the Contractor's License Law for the
Eal; U following reason (Section ] um 5, Rosiness and Professions Code: Any city acmunty
F Ij la�O which rcgniree a permit In amstmct, alter, improve, demolish, or repair any stmnurc
prior to its issuance, also requires the applicant for such permit in file u signed statement
that he is licensed pdmmnt to the provisions of the Contractors License Law (Chapter 9
'qa�0 (commencing with Section 7")ofDi, ision 3 the Business and professions Code) or
that he is exempt headman and the basis for Ne alleged exemptina. Any violation of
iG1C tvN Section 7031.5 by any n,lle m for n p anw
al hjeo, the uppliumt m it civil penalty of
Gnot mom In.. than five hundred dollars ($500).
❑ I, se ownerofthe property, or my employees with wages u their sale compensation.
will do the work, and the structure is not intended diapered for sale (Sec. 7(W. Business
R_ and Professions Cars: The Comracmr'a License Law does not apply to an owner of
property who builds or improves thereon, and who dues, such work hiniselror 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 year of completion, the
owner -builder will have the burden of proving that he did nae build or improve for put.
pose of sola.).
❑ i, as owner of the pnspeny, am exclusively contracting with licensed contractors to
construct The previ (Sec. 7044, Business and Professions Cmde:)'the Contractor's Li
cense law does not apply a an wasted property who builds m improves thermn, and
who cantinas for such projects with a conTractarfq licensed pursuant to the Cientrvnors
License Law,
❑ I am uempt under Soc. , B & P C far this reason
❑ Consultant Fees Paid by Applicant (Initial)
QTY ELECTRIC PERMIT HE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UI' 1'0 200 AMPS
SIGNS ELECTRICAL
SPI7CIAL CIRCLADMISC.
TEMP. ME1 ER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELEM R SQ FT.
TOTAL:
I QTY. PLUMBING PERMIT I FEE /y
Owner—Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of she following dedamtimen:
❑ ave and will maintain o Certificate of Consenum sel&insure for Worker's Compete
,.tion, as provided for by Section 3700 of do, Labor Cade, for the performance r1The
work for which this permit is issued.
❑ 1 have end will maintain Workde Cone muinn hest rmce, as retained by Section
37M of she Lahr Code, for the performance of she week far which title perndt e, issued.
M Workerscol�f S Qtpgn inn Insurance carrier and Policy nwnbern
prier, lPolicy Nti:_KI&O j&6440
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This station need not becmmpleted if he permit is forma, hundred dollars ($IN))
or less.)
I certify that in the perfmnnw¢e of the work for which this permit it issued, ),halI
not employ any person in any trimmer to as to become subject To the Workers' Camper.
Z cation laws of California. Date
2 Applicant
(n NOTICE. TO APPLICANT. If, after making this Cenificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Luton Code, you const
LL7 forthwith comply with such provisions or This permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
U O Iherebyeeffim,thmthere is u construction lending agency forden performance of
U. r+ the work for which this permit is issued (Sec. 3097, Ci, C.)
0 U Lenders Name
Lender's Address
1 certify that I have read this Application and thane that the above information is
In soman. I agree to comply with all city and county ordinances and state laws relating It, QTY,
U Z building construction, and hereby authorize representatives of this city to enter upon the
ams.-mendirool Property in, inspamian purposes.
(We) agree to save, indemnify and keep Imrndess the City of Cupertino against
liabilities, judgments, cosies and expense, which may in any way accrue against said City
in consequence of the'moon, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
HAZARDOUS MATERIALS UISCLOSURE
Will the applicant or future building occupant same or handle hazardous material
as defined by new Cupertino Municipal Code, Chapter 9.12, and ahs I Ito th and Safety
Code; Section 25532(d?
❑yes Fl No
f Will the applicant or future building occupam use equipment or devices which
xps% la'mrrii air cummitinants its defined by the Bay Arca Air Qum ily Management
Di,tia'1
E) Yes FNo
1 have read the hazardous materials requirements under Chapter 6g5 of the Call.
fomia Health & Safety Code, Secaiore 25505, 25533 and 25534. 1 andcrsmnd that if the
building docs not curenhly have n ¢name, ohm it is my responsibility m coney (lie art,o el
of the requirements which must he met prior to issuance of a Cenificate of Occupancy.
PERMIT ISSUANCE
ACTER -DRAIN & VENT- WATER (EA)
BACK I LOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - FA. SYS 'I'PA- 1 INC. 4 OUTLETS
GAS -EA. SYS1'EM.OVER 4 (I:A)
GR ASEGNDUSTRI. WASTE, INTERCEPTOR
GREASETRAP
SEW E.R- SAN ITARY-STORM EA. 200 PI',
WATER HEATER WNENTULECTR (C
WATER SYSTEM?REATING
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
Add RR OR AILD TO MECH.
AIR HANDLING UNIT (TO Input CFM)
AIR HANDLING UNIT (OVER 111,(1(10 CPM)
EXHAUST HOOD GAIMUCTI
HEATING UNIT (TO FILM) M) BTU)
HEATING UNIT (OVER 100,0110 BTU)
VENTILATION PAN (SINGLE. RFSID)
BOILER -COMP (3HP OR 1(10. 00 BTU)
BOILER - COMP (OVER I00,000 BTU)
AIR CONDITIONER
NEW RESIDENT IAL MECH. SQ. PI'.
OFFICE
0
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
❑ ❑ ;f ❑
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL
❑KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI.UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODF,IIREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL:
(2 NEW BLDG/ADDITION ❑DEMOLITION
C1 TENANT- ❑FOODSERVICE
IMPROVEMENT
❑OTHER
SQ. FT. FLOOR AREAPp/g S/SQ, I
A
//y sF� E� , REC'D
7'`a ci " Vr (IIF u
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEF.
PAID
Date Receipts
TOTAL:
BUILDING HE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt p
TOTAL:
ISSUANCE DATE