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CITY OF CLIPERTINO BUILDING -ELECTP
BUILDING DIVISION APPLI N/PERMIT PLUMBING - MECHA
S . 3869
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BUILDING ADDRESS:
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0 ER'S DAME: PHONE: CONTRACTOR'S NAME: LIC NO: !
PHONE:
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 effect.
License Class Lic. #
Date Contractor
ARCHTIECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 70315, 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 Iioensed pursuant to the provisions of the ConiracloPs License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
(hat 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 safe (Sec. 704.4, 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 arc not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner- der will have the burden of proving that he did not build or improve for pur-
pose
as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contracrors Li-
cense Law does not apply to an owner of property who builds or improves Omen, and
who contracts fursuch projects with a contractor(s) licensed pursuamtto the Contractor's
License Law,
❑ I am exempt un r Sec. , B & P C far this reason
Owner Date
WO MPENSATiO CLARATION
1 hereby affirm Oder penalty of perjury Mof the following declarations:
❑ f have and will maintain a Certificate of Consent to self -insure For Worker's Compen.
'inn, as provided for by Seclioo 3700 of the Labor Code, for the performance of the
rork 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 carrier 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 (S 100)
or less.)
I ceiti fy 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. Dare
Applicant
NOTICE TO APPLICANT: if, afier making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
farhwirh comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby a(fatmthat there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state that the above informadan is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby uulhorizc representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree in save, indemnify and keep harmless the City of Cupertino against
liabil ides, judgments, casts and expenses which may in any way accrue againstsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
URCEREW.ATION r `!41 vI/m
of AOOliKntXoOlfaefoI // t ' Date
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)?
❑Yes [I No
Will the applicant or future building occupant use equipment or devices which
emit ha7.ardoas air contaminants as defined by the Bay Area Air Quality Management
�is(ric(?
❑ Yes ❑ No
I have read the hazardous marerials requirements under Chapter 6.95 of the Cali-
fomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand Inn( if the
building does nolcurrently have a tenant, that it ismy responsibility to notify the Occupant
of the requiregfnts which roust be metI4{or to issuance of a Certificate o;Ocqupancy.
❑ Consultant Fees Paid by Applicant (Initial)
I I PERMITISSUANCE I I
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201- I000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
❑ 1? �/ 5f% 7
` B IICIII DING;PF.IIivaT. /NFO C,N a
BLDG ELECT PLUM MECH
21-- ef- Rr-
JOB DESCRIPTION
RESIDENTIAL:
%$FDWL
❑ KITCHEN REMODEL
❑ ADDITION
❑ PLUMBING RE -PIPE
❑ MULTI -UNIT
❑ STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ BATH REMpDELlREPAIR ❑ DEMOLITION
OTHER saw
t '��`
SPECIAL CIRCUITIMISC.
TEMP, METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDGlAD➢ITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
WIMMING POOL ELECTRIC
0 L S-S TCHES-FDCTU
N NTI ELECTR
SQ. Ff. FLOOR AREA
$/SQL. FT.
TOTAL:
TIII'IXKBINGPERMLC`&>`
r
PERMFTISSUANCE
ALTER -- DRAW & VENT - WATER (EA)
VALUATION
BACK FLOW PROTECT: DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
STORIES
TYP[E„JCO(NS�TRUCTIO
FIXTURES -PER TRAP
GAS -EA. SYSTEM -I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY - STORM EA. 200 FT.
WATER HEATER WfVENTIELECTR
WATER SYSTEMII'REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 C'Fld)
EXHAUST HOOD (WIDUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
V EN-nLATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,OW BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL:
DCC. GROUP �� 3 u - 17 —
Date Receipt #
SEISMIC
�, ..
3
ELF
E
I
PLUMB
FEE
'� <
MEC
ICAL FEE
t
CO RUCTION TAX
r
HOUS G MITIGATION FEE
PAID
Date
Receipt#
' I
ISSUANCE DATE"
IED BY:
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