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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING • MECHANICAL
IFI2 5 0 7 6
BUILDING DIVISION BUILDING PROJECT IDENTCATION
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DATE
C- .
063
UNIT # LOT #
CONTRACTOR'S NAME:
bk= F'rC ,,,, lc r -It *-$0S
ADDRESS:
CONTACT: PHONE:
o,y try o4 433-8613
LICENSED CO TRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full force and effect.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
J
ore than five hundred dollars($500).as owner of the property, ormy employees with wages as their sole compensation,
do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Professions 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 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 not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers' Compensation Insurance or a certified copy thereof (Sec. 3800, Lab C.) which
covers all employee's under this permit.
Policy #
Company
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers'
Compensation Laws ofCalifornia. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance 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. I agree to comply with all ty and county ordinances and state laws relating to
building construction, and hereby thorize representatives of this city to enter upon the
above-mentioWtiof
urposes.
(We) ageep harmless the City of Cupertino against
liabilities,judwhich may in any way accrue against said City
in consequenrmit. /�
SiR um of Ap lic Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which emit
hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code. Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE �
APPLIANCES - RESIDEN'
PANELS
UP TO 200 AMPS
20 L- 1000 ANM
POWER DEV
SWIMMING P ELECTRIC
OUTLETS WITCHES -FIXTURES
NEW SIDENTIAL ELECTR SQ. FT. — ---
S7— 1
BUILDING PERMIT INFO
BLDG PLUMB MECH
JOB DESCRIPTION ❑
r O!
SQ. FT. FLOOR AREA $/SQ. FT.
�86O M elA. V $
VALUATION
l6 SLtL4
STORRES TYPE
71
OCC GROUP
J LJ
I
QTY. PLUMBING PERMIT
FEEDA
E IID ZVN 7<J11APS,
PERMIT ISSUANCE
11
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
OUTSIDE FEES
BACK FLOW PROTECT. DEVICE
SANITARY
Y N
RECEIPT #
DRAINS - FLOOR, ROOF, AREA, COND.
SCHOOL TAX
Y N
RECEIPT #
FIXTURES PER TRAP
PARK FEE
Y N
RECEIPT #
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FE
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
PAID
WATER SYSTEM/TREATING
Date
Receipt #
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
TOTAL
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 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 RESID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL
BUILDING FEE
SEISMIC FEE a
ELECTRIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date Receipt #
O
ISSUANCE DATE
P.4
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ISSUED BY: ��