S2891APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION S 2891
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DP:
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OWNER'S NAME: PHONE: V T-ON
�'�JR`j�� OR's NAMEC�� I i LIC NO:
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CONTACT:
LIC NO:
PHONE:
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❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION
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
in full force and a ctq Z
License ss Lic. #
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Date Contractor LL
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
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Licensed Professional
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
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
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
201-1000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
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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
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 ofS
property who builds or improves thereon, and who does such work himself or through
POWER DEVICES
SWIMMING POOL ELECTRIC
- S WITCHES - FIXTURES
his own employees, provided that such improvements are not intended or offered for
N TIAL ELECTR SQ FT.
❑ NEW BLDG/ADDITION
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-
'oe
too 00 14t, 10
❑ FOOD SERVICE
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
TOTAL:
❑ OTHER
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. 1rU2F4G p T
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
PERMIT ISSUA
License Law.
IWam exempt under Sec. B & P C for this reason
ALTER - DRAIN & VENT - WATER (EA)
Owner Date
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 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, COND.
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
w k 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- I INC. 4 OUTLETS
My Work ,r's Cot�penation Insurance dryer and Policy g bei are:
Carrier. %.`'� % L t�+�X policy No.: m 5 �p-7 a�' ��
GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
SEWER - SANITARY - STORM EA. 200 FT.
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-
WATER HEATER WNENT/ELECTR
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sation Laws of California. Date
Applicant
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O ULenders
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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.)
Name
Lenders Address
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
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
building construction, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
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above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ALTER OR ADD TO MECH.
liabilities, judgments. costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
AIR HANDLING UNIT (TO 10,000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
ULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
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Signature of Applicant/Contractor D e
EXHAUST HOOD (W/DUCT)
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)?
HEATING UNIT (OVER 100,000 BTU)
F-1 Yes ❑No
VENTILATION FAN (SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which
_mit hazardous air contaminants as defined by the Bay Area Air Quality Management
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
District?
r_1 Yes ❑ No
AIR CONDITIONER
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. FT.
forma Health & Safety Code. Sections 25505, 25533 and 25534. I understand that if the
buil ing does not currently ve a tenant, that it is my responsibility to notify the occupant
o r mements which .habe met prior t once of a Certific of 0 panty.
Owner or authorized agent Date
TOTAL:
OFFICE
FEE
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN REMODEL
❑ ADDITION
❑ PLUMBING RE -PIPE
❑ MULTI -UNIT
❑ STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ SWIMMING POOLS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL:
❑ NEW BLDG/ADDITION
❑ DEMOLITION
❑ TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. Ff. FLOOR AREA $/SQ. FT.
FEE
VALUATION
STORIES TYPE CONSTRUCTIOP
CC. G APN
BOAAG DIVISION FEES
Y n LANCHECK FEE
ENERGY FEE
SOILS FEE
PAID
Date L Re eipt #
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt #
TOTAL:
ISSUANCE DATE
ISSUED BY: