S0140 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE MIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0140
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBM177AL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: 1 LIC NO:
N/C CONTROL#
ARCH ITECT/ENGINEER: LIC NO: ADDRESS- ❑
CONTACT:
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH�
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RES__��ENTIAL:
w w Z PERMIT ISSUANCE e.
F w in full force and effect DWL [I KITCHEN REMODEL
Q U U License Class - Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
F-Q wW Date • Contractor /�'� - -
ARCMTECT'S DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
F tn Z I understand my plans shall be used as public records MODIFICATION
O Z4 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F rA�-W IMPROVEMENT SWIMMING POOLS
Licensed Professional 201-1000 AMPS ❑
a a OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/REPAIR F1 DEMOLITION
W Q I hereby affirm that I am exempt from the Contractor's License Law for the
XO a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL HER
w 3 w
F. which requires a permit to construct,alter,improve,demolish,or repair any structure
F"w.Oo a prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. l
a N Q 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)or TEMP.METER OR POLE INST. C M ERCIAL:
0.0. that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
X oM w Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT El FOOD SERVICE
W
-. not more than five hundred dollars($500).
IMPROVEMENT
FA
F-1 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC [_1 OTHER
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
W3 COE and Professions Code:The Contractor's License Law does not apply to an owner of OU E 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 RESIDENTftHlwTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,theSQ.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.).
El 1,as owner of the property,am exclusively contracting with licensed contractors to '! �,�(' \,i U If i-'� I(w TOTAL:
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense 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:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. I 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-I INC 4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
GAS-EA.SYSTEM-OVER 4(EA)
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE 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,t 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
O Z sation Laws of California.Date WATER HEATER W/VENT/ELECTR
Z 0 Applicant XBUILDINGF
1.0 ~ NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
P WATER SYSTEM/TREATING
(~ ? become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT.
U O 1 hereby affirm that there is a construction lending agency for the performance of i_4 the work for which this permit is issued(See.3097,Civ.C.)ULender's Name 'U Lender's AddressTOTALI certify that I have read this application and state that the above information is
Vy correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT 1 r FEE SEISMIC FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the
~ above-mentioned property for inspection purposes. O
PERMIT ISSUANCE ELECTRIC FEE f
(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 ALTER OR ADD TO MECH PLUMBING FEE
in consequence of the granting of this permit.
\PPI-WANI t'NDFR\IAND',AND\\III ('OVPIl'\\II[I \LL NO\-POIN'l AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
\(i(RC1.RLUt't \t IONS
t AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor ' Date 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(a)9 HEATING UNIT(OVER 100,00)BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Dale Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management rJYTAL(1-1
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
t' AIR CONDITIONER ISSUANCE DA
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
forma Health&Safety Code,Sections 25505.25533 and 2.5534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT 3
budding 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 66 TAL ISSUED BY: *'
OFFICE