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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING - L T CAL
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO.
^ ^ O
L MV
BIL DING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATi
/M
�, UNIT # LOT #
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J /�i�
OWNERS A PHONE:
CONTRACTOR'S NAME: LIC NO:
N/C
❑
CONTROL #
/;7 C
i
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PLDG ELECT PLUMB MECH
PERMIT ISSUANCE
El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full force and effect.
UJ *1MV104)S
License Class Lic. #
UP TO 200 AMPS
Date Contractor
201 - 1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
SQ, FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDEK DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP. METER OR POLE INST.
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
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
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
�� W
OUTLETS - SWITCHES - FIXTURES
not more than five hundred dollars ($500).
❑ I, as owner ofthe property, or my employees with wages as their sole compensation,
NEW RESIDENTIAL ELECTR SQ, FT.
STORIES
TYPE CONSTRUCTION
will do the work, and the structure is not intended or offered for sale (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 does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
OCC. GROUP
RES. UNITS
TOTAL:
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
QTY. PLUMBING PERMIT FEE
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
FLOOD ZONE
APN
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
PERMIT ISSUANCE
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
AL & VE WATER ( )
FEE SUMMARY
E]I am exempt under Sec. B & P C for this rea
E]
BACK FLOW PROTE IC
OUTSIDE FEES
SANITARY Y N
RECEIPT #
Owner Date
DRAINS - FLO AREA,
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
❑ I hereby affirm that I have a certificate of consent to self -insure, or certificate of
Workers' Compensation Insurance or a certified copy thereof (Sec. 3800 ab C.) which
covers all employee's under this permit.
Policy #
RECEIPT #
FIXTURES - P
PARK FEE Y N
RECEIPT #
GAS - EA. M -I INC. 4NYETS
BUILDING DIVISION FEES
Company
EA YSTE -O 4 (EA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREA USTRL WASTE INTERC OR
GRADING FEE
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TXP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM A. 200FT.
ENERGY FEE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
TER HEATER W/VENT ECTR
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'
PAID
WA SYSTEM NG
Sl
Compensation Laws of California. Date
Date Receipt #
Applicant
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
BUILDING FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
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.)
TOTAL:
ELECTRIC FEE
Lender's Name
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in�nsequenoe of the granting of this peAIR
HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WMUCT)
PAID
Signat o ApplicanUCon actor ate
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
HEATING UNIT (OVER 100,000 BTU)
TOTAL'
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
VENTILATION FAN (SINGLE RESID)
Code, Section 25532(a)?
❑ Yes EI No
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices which emit
BOILER - COMP (3HP OR 100,000 BTU)
P A
BOILER - COMP (OVER 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
Yes El No
J:
FEB❑
8
NEW RESIDENTIAL MECH. SQ. FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand that
fn95
I `�
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
{i11 ►J
Occupancy.
44:3
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE