S 0954 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIDILDING - MECH
BUILDINGDIVISION APPLICATION/PERMIT rLUMBINcA
.D
(r 111111.IIIN1: I'Hf11 Y:Cl C'1'IDEN
❑ Consultant Fees Paid by Applicant (initial)
QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under p n isiom of Chapter 9 (commencing
y�ZO with Section 7")of Uivi.ion3 nfam Bminessand Profession. Cdc,and an, licart is
YUk- in fu 11 force and cff t. r—-�,(�,
a U U License Class -Lie, p
nabDate Con'tac't
Dy ARCHITECTS DECLARATION
Z= Z 1 understand my plats %ball Is: used as public —old'
%O F- 0 Licensed Professional
-� OWNER -BUILDER DECLARATION
Yea
xLLa Ihereby.(fixet that 1par L5exemptfirarnsan the Contacmoo,An,cLaw for the
OyU which
milowing ianon.(Section 1085. nosinessandProfessions Co de: Any city .1 cavity
a y
which requires a permit m construct, alar, improve demolish, or repair any *tronurt
�a prior or as issumce.rd. «qui«s the applicant for such Pemtinn file a signed statement
} and he is licensed income, 1. he provisions of the Camrsmrs License law(Chapter 9
y0i (commencing with Section 1001.( Division 3 of the Business and Pmnn
fesie Code)or
y o C that he is exempt thcmfrma and the basis for the alleged exemption. Any violation of
mSection 1031.5 by any applicant for a permit subjects the applicant (I a civil Mnahy of
t more than five hundred doll., (SNOW.
=O p I.aso.acroflhepmpeny.nrmyemplo)aswimwageeasmeirsnmcmnpcn..don.
L. willdmM1e work, and the %tmaurt,norinendedor initiated for be(SeeTheo, Business
u�1 m and PrI Inas Code: The Contractors License Law does not apply m as owner of
a 3 propeny who builds or improve, thereon, and who does such .ark himself or through
his awn employees, pravided that such improvements via not intended or offered for
sale. IL haviever. the building or improvement is and within one ycmof o-tmplclfon, the
ovener,malder will have the burden of proving that he did not build or improve for put -
,,a of gala.).
Fl 1, as owner of the propeny, am exclusively contracting wit licensed commem, to
consort, the project (Sec. 7044. Business and Mnfessians Code:) The Contractor's Li -
se law does not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a contracm(s) licensed pursuant to the Commeusrs
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 fallowing declaration:
I have and will maintain a Cenilica¢ of Consent to self- Imum Iia Worker's Coni
Nation, as provided for by Section 3100 of the Lubar Code, for the cTformance of the
work for which this person is i_oued.
Fl 1 have and will maintain Worker '.% Compemution Imaturee, as required by Section
311X0 of the LnMn Codelie the perlinmance of the work for which this permit is issued.
My Wcnrke In: cnmJ Pulley numb n
Cumc✓ ycM/%. Policy
CERI'IFICATEOF SN NE [ON
MSF60MWORKIiRS'
CO MPENSAn'ION INSUcit i, f
fI'hd sedinn need not M1c enntplcmd it the pennh ix fnnnm M1undrcd dollars f81 IXI)
or less'
1 ccnify that in the performance of the work lin which this permit Ls a sncd. I shill
anyw
not employ any person in any ,00er so ns m become subject m the WorkersCnmpcm
OZ' nation Laws of Catalonia. Date
Z C) Applicum
y
N(H ICE TO APPLICANT: If, alter nmklng Ihi.a Ccdificate ul Exctnption, you shnuIJ
F-'
forthwith
subject it) the Worker's Com..... a an pmvit Oas of the loud, Code a you nutxt
fonhwi'h cotnply with tech pmvinions ur lhi%Iermil ,hull he Jccned «vokeJ.
Q
CONSTRUCT isa ION oolloaLENDINGoAGENCV
I M1archy udirm that Thiara is u constrvnion lending agency for'hc Mnnrmanee at
CU OR the work for which this Penni' is issued (Sec. 3097. ON. C.)
Lender. Name
U
%' W Lender's Address
1 ccnify per 1 have read This application and stem thutlm ahowe In1'nmtation Is
Fy c rtes'. I agree us comply with all city and county onlinmmes unit %fare laws relanng to,
U Z building conottuatinn, and hereby emhorim mpmsocntmivc: "far, city to enter upon lie
.Five -man .mad properly for inspection purpmes.
(We) agree to scot. Indemnify and keep Leman ea the City of Cupertino against
liabilities. judgments, coats and expenses which play in any way acerae against said City
in consequence of granting of ibis prmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI, NON -POINT
SOURCE REyf}ILATIONS. -
HAZARDOUS MATERIALS DISCLOSURE
W I the applicant or future building accupam start or handle tivaron%ntmerial
as If d by the Cupenlno Municipal Cods. Chapter 9.12, and the Health and Sufaty
Code. Section 25532(0)?
❑Yes C1 No
O
Will to applicant or future Molding accupam use equipment or devices which
emit hicenom s air contaminants as defined by the Bay Arca Air Quality Manugentent
District?
C3 Vex ❑Nn
1 have real the h menclous matcnas scomma enl% under Chapter 6.95 of to Culi-
fomia Health & Safety Code. Sections 25505, 25533 and 25534. I utdemard that liable
building does not currently have a tenon. that it is my m,wasibilay ur unify the occupant
of to ,,ona ento which mush be met pour us issuance of a Cenificate of Occupancy.
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMT'S
SIGNS ELECTRICAL
SPECIAL CIRCUI'TWISC. �I -
TUMP. MITER OR POLE INST.
MOWER DEVICES
SWIMMING PICUL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECIR SQ Fr.
PLUMBING PERMIT
PERM I ISSUANCE
A I:1 FR - DRAIN & VENT- WATER TEA)
BACK FLOW PROTECT'. DEVICE
DRAINS- FLOOR, ROOF. AREA, COND,
FIXTURES - PVR I RAP
GAS -FA SYSTEM -1 INC.4 UU11.ETS
GAS -EA. SYS'U?M-OVIiR 4 (BA)
GREASUINDUST'RI.xi iIN'FERCUPIDR
GREASE I RAF'
SEW ER -SANITARY - STORM 1?A. 2(X1IT
WAI'EIt HaSI'ER IVNIIN'VULECI'R
WNI'ER SYS'I'EMT RIAI ING
WATER SERVICE
NEW RESIDENTIAL I•I.MB. SQ. Ff.
Tfl'1'AL
Q'T'Y. MECHANICAL PERMIT
PrRMI'I' ISSUANCE
ALI ER OR ADD' 11) MECH.
AIR HANDLING UNIT TO 10.000 CFM)
AIR HANDLING UNIT IOVER 10.(XXI CFM)
EXHAUST HOOD (WIDUM )
IIHAT'ING UNIT (n) 10.(X)0 BTU)
HEATING UNIT (OVER 10011(X1 BTU)
VENTILATION FAN (SINGLE RESIDE
ROLLER - COMP OHP OR 1(01(00 BTU1
BOILER -COMP OVER 10010(0 BTII)
AIR CONDIITONER
NEW RESIDENTIAL MCCH. SQ. FF
OFFICE
JOB DESCRIPTION
_S,...._ 0954
N'AO,
APPI.ICAUON SUBMITIAL
❑ KIT'CHEN REMODEL
❑ADDITION
—1
1 \
NIC
[I STRUCTURAL
CON TROL#
MODIFICATION
El INTERIOR
[I CHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
❑ BATH REMODEIIREPAIR
❑ DEMOLITION
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
❑
1& ❑ ❑
JOB DESCRIPTION
RESIDENTIAL,❑SFDWL
❑ KIT'CHEN REMODEL
❑ADDITION
El PLUMBING RE -PIPE
❑MULTI -UNIT
[I STRUCTURAL
MODIFICATION
El INTERIOR
[I CHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
❑ BATH REMODEIIREPAIR
❑ DEMOLITION
❑OTHER
[I NEW BLDG/ADDITION ❑DEMOLITION
L1 TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
A-1
SQ. Cr.
FEE P%,D
Nov
`.`V11 y r'h VALUA
�V (
VSQ.
BUILDING DIVISION FEES
PLANCHECK 19i1!
ENERGY FEE
GRADING FEE
SPOILS FEE
PAID
Date
OPLUMRING
FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION
PAID
Date Ru'ciPl #
TOTAL.:
DATE