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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICKI'ION/PERMIT PLUAfIfING-AI?CIIANICA1,
_........,.., r...,.,t.au,retra.rrav S 0957
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❑ Consultant Fecs Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARA'I ION QTY
1 family affirm that I tan licensed under provisions of Chapter 9 (commencing
with Section ]1100) of Division 3 of the Business and Professions Code, and my license is
in full force and e0ea.
License Class Lie. p
Dam Contractor
ARCHITECTS DECLARATION
w frosaand my plans shall k used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby offimt that I:nn rseram fn,m the Contrwta,, License Law for Inc
fallowing reaxnn. (Section 7031.5. Business and P..fesstoo, Code Any city or county
which requires a Permit at construct. alter, improve, demolish, or repair any sa iture
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he 'licensed pu. a the provisions ofd Contractors, License La (Chapter9
(cc 'ng withS d 7000) of Corsica 3,,f hI 'nes n,[ [Infors,ior,Code)or
do, he ix cu, npt Decollation d the holes for h II g d cx.. oluion. A Y violation of
Section 7031.5 by any applicant far a permit subjects Inc applicant it, a civil penalty of
not mom than Eve handled dollars (S500).
0 I, as owner of the pmpeny, or my employees with wages as their sole compenmtion.
will do the work, and the nmaum is not intended orolfered for sale (Sec ]OLf. Business
and Professions Coda. The Contractor's License Law does not vpoy be an menet of
Property who builds or Improves thereon, and who docs such wnrk himself or through
his own employees, provided that such improvements are not intended or offered lin
sale. IL however, the building or improvement is sold within one yew of completion, the
mer -Wilder will have the burden of pmving that he did not build or imptns'e for pur-
pose oLwle.l
1 a: owner of me prinEwny. am excluosely contractor, with Inetted con tinct no
construct the project (See A94 Hosc d Professions C ) rn C I tet s Li -
came . J amt applyt an ofl lurly he build, or impolite,Flo•m nand QTY:
who contracts for such projects with a contractions) licensed pursuant to the Contmaur'a
license law.
❑lam ewe rand,, Sec. .B le PC fee his a
7;1(late
M I hereby affirm under penally of perrim, one Alpe following drelamtions,
El
(have and will maimaina Cenifica¢of Convent to self-insurtforWnrkehCompen-
ladon, as provided for by Section 37M of the Latin Code, for the performance of the
work lin which this Ismant is issued.
-1 1 have and will maintain worker's Contpenonion Insurance, as required by Section
391X1 of the Labor Cotic, far the performance nrthe work B,rwhich this permit is i,wned,
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need at for ctnnplend i1the pww is follow hundred doll... IS 100)
or leas]
I certify tbalimhe perfnumeare of he wnrk I., which Ihix permit is island, 1111111
not employ any person in any manner ser as to become subject to the W'orkeri Compen-
O Z so ,,an Law, of Califomio, Dee
Z 2 Applicant
ti NOTICE TO APPLICANT: If, after cooking this Cenifiewr of Exemption, you should
become .hjrO m the W ..kcrx Cme,ensmian provisions of the labor Code. you .Mud
forthwith comply with such provisions or permit shall he deemed revoked.
a�
CONSTRUCTION LENDING AGENCY
UO I hereby,hick rte that is sued (Section le, agency for the performance of
� � the walk far which his permit is issued (Sec. JIH9. Cr,Civ. C.)
O U Lender', Noun,
r U Lenders Address
6. I eertily teal I have read this application and one Int the above inG,mramm� s
Lr N correct, I agree to comply with all city and county ordinances and state laws relining to QTY.
f..),Z, building construetion, and hereby authorize representatives of his City 10 ruptm the
above-mentioned property for inspection purposes,
(We) agree a, nave, indemnify and keep harmless the City of Cupertino against
lobilaics,jud,rarm.. crsts and expenses [,I'llnnay In aey way,vecme against sniA City
in mnssquen a of the graming Of (his 1-111.
n VPi:ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
I IA]ARDOUS MATER( U6CLVlURR
Will the applicant or furore buildings pant store Or handle hVwtous mineral
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)'t
Yes nNo
Will the applicant Or future an If ng occupant use eyuipmcnt or devices which
unit haardous air contaminants as defined by the Bay Area Air Quality Monapcnsnl
District?
❑Yes ON.
1 have read the hawdaus nic er als mquircments under Chapter 6.95 of the Culi-
fomiu tl does dr Safety Codc. Satins 25505. 3533 and 25591 to mady th (hal if the
Call -
building dons not currently have a met p that o is ua responsibility Clility co notify the pancy. m
of he rtyaimrrenta wnien mea he ma prior m issuance Ira cendicwe of Occupancy.
ELECT'RIC PERM IT'
PERMIT ISSUANCE
APPLIANCES - R BSI DEN'1'IAl.
PANELS
UIs TO 200 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
TEMP, METER OR IDLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWR CITES - FIXTURES
N FIV BESIDES I'IA I. ELECTS
PLUMBING PERMIT i
PERMIT ISSUANCE
A1:1ER-DRAIN R VENT- WATER WA)
(SACK FLOW PkGIFCT. DEVICE
DRAINS - FLOOR. ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYS'I EM -1 INC.4 0U'I I.1H S
GAS - IA. SYS TEM-OVER 4(EA)
GRFASEANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SAFE I'ARY - STORM 17A. 21X) IT.
WATER HEATER W/VEN DELECTR
WATER SYSTENIG HEATING
WATER SERVICE
NEW BESIDE TIAL PLMB. SQ. Fr.
MECHANICAL PERMIT
PERMIT ISSUANCE
A A BEE OR ADD TO MECH.
AIR 14ANDI-ING UNIT TO HE.000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNI I' (TO H10.000 B'I'G)
HF.A'I'ING UNIT (OVER 100.000 BTU(
VENTILATION IAN (SINGLE RISID)
BOILER -COMP (3HP OR I0AIXXI H'I'U)
BOILER -COM(' (OVER 100,000 HTLD
AIR CONDI I'HINER
NI7W RESIDENTIAL MECH. SQ. PT.
OFFICE
■N
PERMITINFO
U'UU., lIIVV
STORIIiS TYPE
0 , X ❑ ❑
FEES
FEE
JOB DESCRIPTION -
RESIDENTIAL
0 SFDWL 0 KITCHEN REMODEL.
O ADDITION G PLUMBING RE PIPE
O MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR 0CHIMNEYREPAIR
IMPROVEMENT O SWIMMING POOLS
0 BATH REMOOEfJNEPrjJ� I�1jL Q�11rr
O OTHER 1/r1i-k/�dtl"/i..�1�j'��
IiNGR I.
GRA VG FEE
SOILS FEC
PAID
COMMERCIAL,
CINEWBLDGIADDITION 0DEMOLITION
GTENAM1T - [I 1700D SERVICE
IMPROVEMENT
O OTHER
TOTAL:
U'UU., lIIVV
STORIIiS TYPE
$/SQ. IU.
ERIVNIGDIVISION
FEES
PLANCHE( 1 li
IiNGR I.
GRA VG FEE
SOILS FEC
PAID
ao Receipt4
TOTAL:
❑UILDI , FEE
FEF.
SEISMI . FEE
ELF IC FEE
PLUM ING FIJI
MECH LAICAL FEE
CONSTR ION'TAX
HOUSINOMI'll "ION PEG
PAID
UIt, 161,,11)1#
TOTAL:
ISSUANCE DDAAATTEEE
ISSUED BY: 9xi l_-�—
$/SQ. IU.