S3223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 3223
BUILDING PROJECT IDENI7FICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
ARCHITE /ENGINEER: LIC NO: ADDRESS &T i d PrJ_ AIV fy ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
D I a ❑ ❑ W ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
A 04 Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
Fo n in full force and ect PERMIT ISSUANCE
'%W F f - .�{ )� ❑SFDWL El KITCHEN REMODEL
- U U License Class=�[•���Lic.#
Z WW Date j` ��""� ContraWc, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F-]to ARCHITECT'S D PANELS ❑MULTI-UNIT ❑STRUCTURAL
z M Z I understand my plans shall be used aMODIFICATION
UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F W licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
a OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEL/REPAIR El DEMOLITION
1 a x¢ I hereby affirm that I am exempt from the Contractor's License Law for the
O 0.0 following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHE
1 W O h which requires a permit to construct,alter,improve,demolish,or repair any structure �QYG�,.
1 a prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. �.C1-
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 `L-
CL'A 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
p,c a that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
in []TENANT El FOOD SERVICE
not more than five hundred dollars($500).
IMPROVEMENT
Q ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL EL RIC
A will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER
W 3°O and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-S HES-FIXTURES
-. 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 NEW RESID IA LEC!R SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
r_1 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
Ot
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMI FEE
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIOD
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
"3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker' non I s nce c er and Policy n FF r
Carrier. Policy No.: 1M6 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
sation Laws of California.Date WATER HEATER WNENT/ELECTR
z O Applicant GRADING FEE
i_4 � NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
I"+ ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
W
> forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
�0. A CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
:) Z I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
U
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL:
Lender's Name
V Lender's Address TOTAL:
aI certify that I have read this application and state that the above information is BUILDING FEE
Ln correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT
V Z building construction,and hereby authorize representatives of this city to enter upon the
~ above-mentioned property for inspection purposes.
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against C FEE
liabilities,judg nts,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in conseque of theSontractor
of thi permit p PLUMBING FEE
APPLIC UN DS D W L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) tj C N�A
SO REG
AIR HANDLING UNIT(OVER 10.000 CFM) (� CONSTRUCTION TAX
Signature of ApplicaDate EXHAUST HOOD(W/DUCT) By HOUSING MITIGATIONWE/
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal C.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑ o
VENTILATION FAN(SINGLE RESID) PAID
Date cei
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 BOILER-COMP(3HP OR 100,000 BTU)
TO
District? BOILER-COMP(OVER 100,000 BTU)
F1 Yes 444� ,
AIR CONDITIONER
I have read the hazardous m s requirements under Chapter 6.95 of the Cali- ISSUANCE DATE Q
forma Health&Safet e,Se�,t
5533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does tly have s my responsibility to notify the occupantof the req in h'ch must ssuance o Certifi e Pap.
L2=or au orized agent Date TOTAL:
ISSUED BY: ,
OFFICE