S4301 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL S 4301
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
c.. & ^� - N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE BUILDING PERMIT INFO
I ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Ex
LICENSED CONTRACTOR'S DECLARATION . ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing QTYJOB DESCRIPTION
A 0:Z with See 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:
W O p
H W in full force and a ct PERMIT ISSUANCE ElSFDWL El KITCHEN REMODEL
V E— License Clas C Lic.#
H z 4Uc] Dale Contract.. —� APPLIANCES—RESIDENTIAL ElADDITION ElPLUMBING RE-PIPE
Q 0. ElMULTI-UNIT El STRUCTURAL
ARCHITECT'S DECLARATION
F,O n PANELS MODIFICATION
v1 z I understand my plans shall be used as public records i
E UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P4 F"W Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS
Q x J OWNER-BUILDER DECLARATION
0.' OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
0;a Q I hereby affirm that I am exempt from the Contractor's License Law for the
O.3 0.H following reason.(Section 7031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHERA
W w0 to which requires a permit to construct,alter,improve,demolish, r repair any structure /Y �`E r— TZ-
prior �'
to its issuance,also requires the applicant for such permit to e a sig d statement SPECIAL CIRCUIT/MISC.
W r a that he is licensed pursuant to the provisions of the Contr or
Lc aw(Chapter 9
W a A (commencing with Section 70001 f Division 3 of the B s d Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
0.0.oa that he is exempt therefrom an the basis for the leg tion.Any violation of NEW BLDG/ADDITION [I DEMOLITION
�'n Lt Section 7031 5 by any apphe t for a permit s ject.the plic t to a crvd penalty of POWER DEVICES El TENANT [I FOOD SERVICE
Con W" not more than five hundred Mars 1$5001.
IMPROVEMENT
A ❑I,as owner of the grope ,or my employees wi ges as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
F. will do the work,and the s eture is not i nde r offered for sale(Sec.7044,Business
3 and Professions Code:T e Contractor's ens Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES Y./V
property who builds or i proves there ,a who does such work himself or through
his own employees,for ided that s imp vements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the buil i rovement i.sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the bur of proving that he did not build or improve for pur-
pose of sale.). O
LI
❑1,as owner of the property,am xclusively contracting with licensed contractors to IOTA
construct the project(Sec 7044,B siness and Professions Code:)The Contractor's Li-
cence Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT 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. STQ&IFS TYPE CONSTRUCTION
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
�1 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.GROWP APN
My Worker's Compensation Insurance carrier and Policy number
Carrier: J1�'1J Policy No.:Ix 7I !, l GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR _ 2 mn
(This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP i''I
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. t,
not employ any person in any manner so as to become subject to the Workers'Compen- ENERG
O Z sation Laws of California.Date WATER HEATER W/VENT/ELECTR ADING FEE
Z C) Applicant
0-0
, NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
become subject to the Worker's Compensation provisions of the Labor Code,you must
wforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
U Q I hereby affirm that there is a construction lending agency for the performance of Date Receipt#
Hthe work for which this permit is issued(Sec.3097,Civ C.)
w Lender's Name TOTAL:
O U Lender's Address TOTAL:,!
>y a 1 certify that 1 have read this application and state that the above information is BUILDING FEE
to correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
U ,Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
~ above-mentioned property for inspection purposes.
PERMIT ISSUANCE ELECTRIC FEE
(We)agree to sane,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this permit.
!(,\\I-t'A l 1f RS I\NDS AND \III C(>!s1Pl.l'\\'1 I-11.\II \()N-POl\I AIR HANDLING UNIT 10,000 CFM)
ti()t Kc I�K/I-.Gli�,,�t MECHANICAL FEE
C — i� G/'t AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor fate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
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 Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes PAID
VENTILATION FAN(SINGLE RESIll) Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3HP OR 100,000 BTU) Wolof
mit hazardous air contaminants as ned by the Bay Area Air Quality Management TOTAL: L-
District? BOILER—COMP(OVER 100,000 BTU)
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the rzd�irients which must be met prior to issuance of a Certificate of Qc pan•.
�-E)wrier or authorize ent Date- TOTAL: ISSUED BY.
OFFICE