30517APPLICANTTO FILL IN INFORMATION WITHIN RED LINLe.S - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL. PERMITNO. /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL (O 17
RIIII IHNC PRntri(r usyNTIFICAI'IOV 3 .L
NAME:
QxjiBg
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provisions ofChapter 9lennnnencing
0 with Section 7000) of Division 3 ofmc Businessman Professions Code, and my decaseiv'
ila full force and eft«
U Limp. Class SIU De.x_ 7uo113 PCrx C.
iDatr Cnnvanmt c1e_aCLLFJ
y ARCHITECTS DECLARATION
Z I understand my plans shall lb, used as public records
W Licensed Professional
that I a exempt
DECLARATION
Q 1 hereby affirm Section nt 1 am exempt tram the fes6onsContractorCo License law for Ne
followV which ag rcawa. ermit]03LS. Business land ve. demolish.
or Any city or county
y whish requires n permit re ennswa, ahoy, improve, demolish, or repair any structure
iss
Real heor slice sedpalarrc to the the
ovisio s of for such Contractor's
Lie nse Lae(Chaptem
Real he is licensed pursuam 7 the provisions of the Cnmmnor's License Law (Chapter r
Q(car he
(commencingwithStenon. ad of Div isioor of the nosiness sand ProfessionsAnCod)or
yr then he is exempt thuefmm coil the basis for the alleged exemplinn. Any viohnion of
0.y Section 7031.5 by any applic t for a permit subjects the applieum Io a civil penalty of
not moredun five hundred J ars 155in
] I, oso ,.Map peny rmy Inyee, i wages res their sole compensation.
well do the k, and th stmt rein nm ormlPcrcdfor sale (See ]W4. Rosiness
and Profess on c he m toe ¢ease hvw Jne, m4 apply to an owner of
.. pmpcny w u r v s thereon, and who Jwe such work himself or through
his own empk es ` W t such improvements arc not intended or offered for
sale. ll howeve, th an ding or improvenmm is snlJ within one year of completion, the
owner -builder will have the hunlen of proving that he did not build or improve for par- J
Pnee of sole.).
C I, as owner of the property, am exclusively contracting with licensed contractors to
construct Ne project (See 1014l Business and Professions Code:) The Commences Li-
cense Law does not apply mon owner of pmpcny who builds or improves Damon, and QTY,
who contracts for such projects with a carnations) licensed pursuant o the Commences
Littn¢ law.
C l am exempt under Sec. ,R&P C for this rcsnn
.at Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ..act the following declsmtiom:
1 have and will mountain v Ccnifram of Consent to ndLinsum for Worker s Cooper -
in, as provided for by Section 370" al the Labor Code, for the performance of me
V'I have and will maintain Warkees Compensation Insurance, as occurred by Section
370" of the Labor Cdc, for the performance of the work for which Ihis put is i ... ad.
MyW kers Cnrnpe�rsation insnmuc f�errnier and Policy pptsumherXiYce
Cannata At lie A xNlli6 Policy No.: N l737/A
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This welkin readmit be atmplded if the pemdt is (mme hundred dollura ($1 W)
or los.)
1 certify that in are Performance of he work for which Nis permit is issued, l shall
nm employ any person in any annular, no as m become subject to the Work .0 Cnmpen-
z cation Laws of California. Dote
z 0 Apph,am
h NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
a; become subject to the Waukee, Compensa ion provision., of the Labor Cade, you must
forthwith comply with such provisions or this pemnit shall he deemed revoked.
d
U z CONSTRUCTION LENDING AGENCY
V 0 I hembywhich
thi that mit i is sued construction lending agency for performance of
U the work for which mus permit i, issued (Sec. 3p97; Civ. C.)
U Leader's Name
U
Lendeer's Addrcsv
Fq I cenify that 1 have mad this application and state that Ne above information is
h correct. l agree m comply with nil city unJ coumty orJinanas mail crate laws relating m QTY,
U Im Idingconsuucdnn, and hereby aummiu rcpresnnativcs of mus city menmr upon th'c
above-meminnetl pmpcny for inspection purposes.
(We) agree to rove, indemnify and keep harmless the City of CuNaino against
liabilities, judgment,, costs and ex,misus which may in any way same against said City
in asequence of the granting it his permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU 1REGULATIONS.
1( 9-l9-9&
Sngnatoms Appir VCnntraam Date
HAZARDOUS MATERIALS DISCLOSURE
Will the micard or future building cecupam storeor handle ho,im1c ,material
as defined by me Connemara) Municipal Cod. Chapter 9. 12. and the Hcahh and Safely
Code, Section 255321a1^.
❑Yes C] No
Will the applicant or future budding occupant we equipmenl or device,, which
emit hazardous air contaminants as defined by the Bay Ares Air Quality Management
Dltdny
❑Yes CNor
I he,, read the hazmJnu, materials requirement, under Chapter 6.95 of me Cali-
fornia Hwlth & Safety Code, S«tion 25505. 25533 wd 25534. I understand that if me
building does not currently have a mment that it is my eesrymsibility to witty are occupant
of the endearments which must he met prior to issuance of a Cendicaa of Occupancy.
Owner or arthonzed agent Date
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 20B AMPS
SIGNS ELECTRICAL
0
JOB DESCRIPTION
DENTIAL
RESIDENTIAL
CSFDWL
C KITCHEN REMODEL.
❑ADDITION
[I PLUMBING RE -PIPIT
C MULTI -UNIT
CSTRUCTURAL
NEW RESIDENTIAL ELECTR SQ pT.
MODIFICATION
C INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
PLUMBING PERMIT FEE
C BATH RF,MODEUREPMR CDEMOLITION
COTHER
•t VALUATION
SPECIAL CIRCUIT/MISC.
BUILDING FEE
TEMP. METER OR POLE INST.
COMMERCIAL
[D NEW BLDG/ADDITION [I DEMOLITION
b TENANT CFOOD SERVICE
IMPROVE T �
OTHER ` n�
C OTHER 1 ,V`
e
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWI3'CITES -FIXTURES
NEW RESIDENTIAL ELECTR SQ pT.
Floo2 DarA �weK
SO, FT. FLOOR AREA
SEP i 1 t7
i
n ����
$/SQ. ET.
114061t V -4t3
PLUMBING PERMIT FEE
PERMIT ISSUANCE A
/
AL'I'KE - DRAIN & VENT -WATPN CA) /
•t VALUATION
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
DRIES
'TYPE CONSTRUCTION
FIXTURES-PERTRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
,pROUT
5/C/tel
APN
GAS -EA. SYSTEM -OVER 4 (EA)
GRRASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 20" FT.
F.NIiNGY HE
WATER HEATER WNENT/ELECfR
GRADING FEE
WATER SYSTEM/TREATING
SOILS FEF,
WATER SERVICE
PAID
Date Receipt#
NEW RESIDENTIAL. PCMB. SQ. FE
TOTAL:
MECHANICAL. PERMIT FEE
BUILDING FEE
SEISMIC PER
PERMIT ISSUANCE
ELECTRIC HE
ALTER OR ADD TO MECH.
PLUMBING PEE
AIR HANDLING UNIT CFO 10.00 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10.001 CFM)
CONSTRUCTIONTAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT GO 100,000 BTU)
HEATING ON] 'I'(OVER 100.010 BTU)
PAID
VENTILATION FAN (SINGLE RFSID)
P OR I0"n100 BTU)
Rccnplx
TOTAL:
VER 10).0X1 BTU)
MMECHDam
ISSUANCE DATE
ISSUED BY:T/�
.
MECH. SQ. FT.
TOTAL:
OFFICE