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S1555awz W 00 W ix U F vV"i¢a Foto z4A a wa �Oa irn>1 Fz>"' �xA APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO Fl:l 11 NU. 1555 BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL in full force and effect. BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: Date Contractor c /C1�?bNA ►� G�. I understand my plans shall be used as public records OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the ,tCHITECT/ENGINEER: V LIC NO: ADDRESS: prior to its issuance, also requires the applicant for such permit to file a signed statement �1 CONTACT: PHONE: that he is exempt therefrom and the basis for the alleged exemption. Any violation of �� o ) Q Q 7 ❑ Consultant Fees Paid by Applicant (Initial) _ LICENSED CONTRACTOR'S DECLARATION IQtr Fl:l 11 NU. 1555 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 APPLICATION SUBMITTAL DAI in full force and effect. License Class Lic. # CONTROL # Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR MPROVEMENT ❑ SWIMMING POOLS ATH REMODEL/REPAIR ❑ DEMOLITION 11 OTHER OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's 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 Contractor's License Law (Chapter 9 COMMERCIAL: ❑ NEW BLDG/ADDITION ❑ DEMOLITION ❑ TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER (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 7 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, 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, 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 pur- pose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to 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. 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 caner Date WORKER'S COMPENSATION DECLARATION 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- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 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. My Worker's Compensation Insurance tamer and Policy number are: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) 1 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' Compen- sation Laws of California. Date Applicant 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 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.) Lender's Name Lender's Address 1 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 Q't`y building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (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 in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. LA Signature of A cant/Contmctor Date HAZARDOUS MATERIALS DISCLOSURE 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 .ut hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No 1 have read the hazardous materials requirements under Chapter 6.95 of the Cah- fornia Health & Safety Code, Sections 25505, 25533 and 25534. 1 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. or authorized agent Date ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS 201-1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS — SWITCHES — FIXTURES NEW RESIDENTIAL ELECTR SQ FT. PLUMBING PERMIT PERMIT ISSUANCE ALTER — DRAIN & VENT — WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS — FLOOR, ROOF, AREA, COND. FIXTURES — PER TRAP GAS —EA. SYSTEM- I INC. 4 OUTLETS GAS — EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASE TRAP SEWER — SANITARY — STORM EA. 200 FT. WATER HEATER W/VENT/ELECTR WATER SYSTEM/TREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. 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) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE SQr Fr. FLOOR AREA 23 �VsD FEE `fryO FEE $/SQ. FT. VALUATION P �dna STORIES 11 TYPE CONSTRUCTIOP BUILDING DIVISION FEES PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID 1 Date /� a tpt # / \ l TOTAL: BUILDING FEE .14 SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION T HOUSING MITIGATI N FEE PAID Date Receipt # TOTAL: ISSUANCE DATE ISSUED BY: Fl:l 11 NU. 1555 SANITARY NO. APPLICATION SUBMITTAL DAI NIC CONTROL # BUILDING PERMIT INFO BLDG ELECT PLUMB MECH FEE JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR MPROVEMENT ❑ SWIMMING POOLS ATH REMODEL/REPAIR ❑ DEMOLITION 11 OTHER COMMERCIAL: ❑ NEW BLDG/ADDITION ❑ DEMOLITION ❑ TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER 7 SQr Fr. FLOOR AREA 23 �VsD FEE `fryO FEE $/SQ. FT. VALUATION P �dna STORIES 11 TYPE CONSTRUCTIOP BUILDING DIVISION FEES PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID 1 Date /� a tpt # / \ l TOTAL: BUILDING FEE .14 SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION T HOUSING MITIGATI N FEE PAID Date Receipt # TOTAL: ISSUANCE DATE ISSUED BY: