26480CITY OF CUPERTINO ""'"""" ""'-"""""' '
APPLICATION/PERMIT PLUMIIING-MECHANICAL 26480
BUILDING DIVISION Rnu naw: nvOssxrr mRNTu'IcnruaN
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LICENSED CONTRACTOR'S DECLARATION
M=Z I hereby uffirmthat l am licensed underprovisionsof CTapter9(commencing with
dOC Section 70(0) of Division 3 ofthe Business and Professions Code, and my license is in
y�Ufull force end effect.
Q(_2W License Clete LiC.N
may are Contractor
,z8D ARCI31TEC'S DECLARATION
I unintentional my plans shall be used as public records.
y uI
Licensed Professional
OWNER -BUILDER DECLARATION
yp�d(OaF I hereby affirm that I am exempt from the Contractors License Law for the
W S LLm< following reon. (Section 7031.5, Business alit Profesaioa Cade: Any city orcounsy
(=EZ ONJ which requirea permit to construct, aper, improve, demolish, or repair any structure
':p prior to its issuance, also requires the applicant for such petmitm Ble asigned soumem
til Q5 that he is licensed pursuant to the provisions of the Conoactors License Law (Chapter
C.6L 9(commencing with Section 7") of Division 3 of the Business and Professions Code)
F�
_y or that he is exemu
phcrefrom unit the basis for the alleged exemption. Any violation of
kF Q Section 7031.5 by any applicants for a permit subjects the applicant to a civil Penalty of
t no, more than five hundred dollen ($500).
C o ❑ Las ownerofthe prtmpeny, ormy employees with wages as their sole compensation.
y will do the work,aad thesvuctum is not imendadoroffered turnele(Sec. 7014, Business
and Professions Cade: The Contractor's License law does not apply to an owner of
,wn c�y whobuilds ofimprovesthanesand whodoes such work oruff for through his
employees provided provehImprovememsarenmyear oedo pletiod for ole. r-
however thebve be burden
f pnwir,Omahadiinoaywofcampiniogtheowner-
sale). will have the burden of proving Omaha did not build ar improve for purpose of
sale).
EI 1, ca; owner of the property, annexclusively contracting with licensed mantructurre to
Licari the project (Sec. to
Business and Professywhobuild Code) Tim Contractors
Manse Law does not apply to an rwnerofpropeny whobuildsnrimproveathereon, and
who convects fm such project with a contracmt(s) littrwd punuanuo the Convamrs
License Law.
❑ I em exempt under Sec. . B & P C for this reason
Ow
Data
WORKMAN COMPENSATION DECLARATION
❑ Ibemby off. that l have acmileme ofcommziuo self -insure, or attrtificate of
Workers' Compensation Insurance msteconfed copy thareof(Ses. 3800, lab C.) which
covers all employee's under this permit.
Policy N
Company
❑ Candles] copy is hereby furnished.
❑ Qnified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complered If the Permit is for as hundred dalton ($100)
or less.)
1 cenify that in the performance of she work for which this permit is issued, l shall
not employ any person any marrom so m to become subject to the Workers'
z Compensation Lawsof Califamia. Dau
Applicant
NOTICE TO APPLICANT:IL.ftm making this Certificate of Exemption, you should
e—I pJ become subject to the Workers Compensation provisions of she labor Code, you must
CLYi ; fonhwith comply with such provisions or this permit shall be darned revoked.
aQ CONSTRUCTION LENDING AGENCY
Z 1 hereby affirm that them is a cmame,ir n lending agency for Ne performance of
I..1 O the woh for which this permit is issued(Sce. 3097, Civ, C.)
Ci. a Lender's Nome
O Lender's Address
W1 cenify that 1 have read this application and mute that she above information is
correct. I agre, to comply with all city and county entrances and state laws relating to
building construction, and hereby aohotiza representatives ofthis city to enter upon the
V ahoveormini red property for inspection purposes.
(We) agree t0 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 gnnsing of this permit.
Si tore MAppli Co valor Dote
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stem or handle hazardous material
as defined by the Cupertino Municipal Cole. Chapter 9.12, and the Health ad Safety
Code, Section 25532(u)?
❑ Yea ❑ No
Will the applicant or future building occupant use equipment or devices which emit
hazardous air contaminants as defined by the Buy Am Air Quality Management
District?
1 ❑Yes ❑ No
1 have read she hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a team, that it is my responsibility in notify the
reaper of the requiicmems which must be met prim to issuance of a Comftam of
Oacapancy.
Owner or authorized agent Data
SS:
PAID
Dau Receipt N
TOTAL:
PLUMBING PERMIT FEE
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
PERMIT ISSUANCE '
BLDG ELECT' PLUMB
sarF ❑ ❑
MECH
❑
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP T0200AMP5
MECHANICAL FEE
JOB DESCRIPTION
SA NITARY
SIGNS ELECTRICAL
SPECIAL. CIRCUITIMI$C,
TEMP. METER OR POLE INST.
POWER DEVICES
OUTLETS - SWITCHES - FIXTURES �O7 �IJ
NEWRESIDENTIALELECIR _SQ.FT. STORIES
TOTAL:
PAID
Dau Receipt N
TOTAL:
PLUMBING PERMIT FEE
ROGDZONE
SEISMIC FEE %Jko
PERMIT ISSUANCE '
ALTER - DRAIN & VENT - WATER (BIG
FEE
FEE SUMMARY
BACK FLOW PROTECT. DEVICE.
MECHANICAL FEE
OUTS IDEFEff—
SA NITARY
Y
RECEIPT N
D R ROOF. AREA, COND.
Fl TURES-PERTRAP
SCHOOL TAX
Y
RECF.IPTp
PARK FEE
Y
RECEIPT#
AS - EA. SYSTEM -1 INC. 401011, PS
BUILDING DIVISION F
AS - EA. SYSTEM -OVER 4(EAI
PLANCHECK FEE
GREASEIIND I L WASTE C
OR
GRADING FEE
GREASE TRAryly_
SOILS FEE
SEWER - SA - STORM EA. 2001IT. 1
ENERGY FEE
-SQ.FT.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.1)O0 CFM)
EXHAUST HOOD (WIDUCn
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (RHP OR 100.05) BTU)
BOILER - COMP (OVER 10(1,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL:
A� 4
O
yr e . 9d
PAID
Dau Receipt N
TOTAL:
BUILDING FEE �►a
SEISMIC FEE %Jko
ELECTRIC FEE
FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Data Receipt N
A� 4
O
yr e . 9d