S 0798FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
oTavn BUILDING - EI,EC'rR1CAL
APPLICATIONIPERMIT
❑ Consultant Fees Paid by Applicant (Initial)
I berchy affirm the, 1 am licensed under Provisions of Chnpter 9 (commencing
11
with Section 1W(1) of Division 3 of the Business and Profs¢ions Code, said an, license is
in full free and effcn.
BUILDING PERMIT INFO
License Class J, In
BLDG ELECT'
❑ ❑
Dam Contractor
ARCHITECT'S DECLARATION
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑ KITCHEN REMODEL
❑ADDITION 0 PLUMBING RETIPE
❑MULTI -UNIT ❑STRUCfURAI.
MODIFICATION
C3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR DEMOLITION
❑ OTHER
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 herchy affirm that I em exempt from the Comenuor's ❑rmim Law for the
following reason. (Section 103 1,5, Business and Rofesoons Csdc: Any city or county
which requires a permit to construct, alter, improve. demolish, or repair any suucmtc
COMMERCIAL:
❑NEW BLDG/AUDITION
❑TENANT
IMPROVEMENT
[]OTHER
prior to its issuance, also requires the applicant for such permit to File a signed statement
that he is licensed puc%uant to the prom ision%of the Comrenor's License Law (Chapter 9
(commencing with Section 1(00) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to u civil psoulty of
not more Nan five hundred dollars ($510).
❑ 1, as owner of the pwpeny, or my employees with wages as their ole compensation.
will do the work, and the structure is not intended or offered for rule (See 7GUL Business
and Pmfnkare, Code: The Commemrr License Law does not apply ,, an owner of
pmpeny who builds or improves thereon, and who does such work hunwif or through
his own employees, pmvided that such impmverw nlr am not intended or oB2red for
rale. IL however, the building or inipmvemrnt is sold within one year ufcmnpledu n. the
ownef-huildcr will have the burden of proving that he did not Wild or improve for pur-
"m of sola.).
❑ 1, as Owner of the property, tan exclusively emnrecling with licensed contractors to
construct the pmjmt (Sec. 7044, Business and Pmfessiom C d,) The Gmlmrtors Li.
QTY,
cence Law does not appy to an owner of pmPeey who build%mangroves thereon, and
who contracts for such pamjecm with a commanr(s) licensed pursuant o the Contractors
License Law.
I am exempt under Sec. B & P C for this %caro.
Owner [)are
WORKER'S COMPENSATION DECLARATION
1 herchy affirm under Penalty of Perjury one of the following declarations:
I have and will maintain a Cenilicee of Conwnt m eclpmsure for WorA is Compen-
sation, as provided for by Section 3100 of the Labor Code, for the scommianm of the
work for which this Permit is issued.
❑ 1 have and will maintain Worker', Compensnoor Inwmnce. in, requited by Se
370 of the Lahr Code, for the performance ofthe work for which this permit is is.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OP EXHMPHON FROM WORKERS'
COMPENSATION INSURANCE
("is x it.. need oat be completed if the permit is for one minimal dollars ($110)
or less.)
sanity that in the per orm ince ofthe work forwhich this pemtit is iswed, l shall
not employ any person in any manner so as to become subject a the Workers Compen-
sotion Laws of Culifnmiu, (late
Applicata I
NOTICE TO APPLICANT. IL after making this Cenificme of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such provisions or his permit shall he dermad revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affi mi that there is a construction lending agency far the performance of
the work for which this permit is issued (Sec 3091, Civ, C,)
Under', Name
Len der'% Address
1 sxnify that 1 have read this application and ,are that the have intro armtom is
QTY
correct. l agree mcomply with all city and county ordinances and state laws relating to
building construction, unit hereby authorize representatives of this city m emef urym the
alm,wernmet l property fair m,pcmiml purposes.
(We).,seem save, indemnify and keep honnle, the C"ry"' Cupenino against
liabilitics,judgmems, costs and expense, which may in any way accrue against aid City
consequencein of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant m'mnrs baildingoccupam� tore or handle huzaNna%maenal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Ihealth and Sufcty
Cade, Section 25532(0)?
C] Yrs
Will the applicant or future Wilding occupant use equipment or devices which
it hamrdous air contaminants as defined by the Bay Area Air Quality Management
sined?
❑Yes No
1 have rend the hazardous maerials nyuircment, under Chapter 6.95 of the Col.
fomia Health & Safety Ggemions 25505, 25533 and 25534. 1 undentand that it the
ELECTRIC PERMIT
FERMI IISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP 10 200 AMPS
SIGNS ELEC I'RICAL
SPECIAL. CIRCUIT/MISC.
TEMP. METER OR POLI: INST.
POW13R UEVIC IS
SWIMMING ELECTRIC
NEW RESIDENTIAL ELI-ff( , SQ FT.
0798
NO.
PLUMBING PERd.11T _.�' I FEE
PERMIT ISSUANCE si
ALTER - BRAIN & VENT -WATER (BA)
BACK FLOW PROTECT DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
��FIXTURES - PER TRAP
fdAFR lig.YS iM I INCA OU'FLE: S
WASTE IMTRCE17OR
GREASE IRAI'
SEWER -SANITARY-STORM EA, 20e, IT.
WATER HEATER WNENTXLECTR
WATER SYSTEM/ SEATING
WATER SERVICE
NEW RESIDENTIAL PLML SQ. ET
MECHANICAL PERMIT I FEF.
PERMIT' ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER I0,000 CFM)
EXHAUST HOOD (W/DUC'T
HEATING UNIT (TO 100.000 BTU)
HGTING UNIT (OVER 100.0)(11 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COM(' (3HP OR 100.000 RTU)
BOILER - COMP (OVER 10)(1010 BTU)
AIR CONDITIONER
NI:N' RESIDENTIAL MECH. SQ. PT.
OFFICE _ (L
SQ. FL FLOOR AREA $/SQ. FT
VALUATION
STORIES 'TYPE CONS rRUC1'101
DEC. GROUP APN
BUILDING DIVISION PEES
PLANCHFCK FEE
ENERGY FEE
GRADING FEE
SOILS FIE7
IAN An PNU
'Date RcceiPll
CITY ur uurrisimi
BUILDING FEF,
SEISMIC PEE
ELECTRIC FET:
PLUMBING PH 9 /G
MECHANICAL. Flit: /Y
CONS'T'RUCTION TAX
HOUSING M11 MA'HON FEE
PAID
Dam Rcuuptl
DATE
11
BUILDING PERMIT INFO
BLDG ELECT'
❑ ❑
PLUMB MECH
❑ ❑
FEL
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑ KITCHEN REMODEL
❑ADDITION 0 PLUMBING RETIPE
❑MULTI -UNIT ❑STRUCfURAI.
MODIFICATION
C3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR DEMOLITION
❑ OTHER
+O
COMMERCIAL:
❑NEW BLDG/AUDITION
❑TENANT
IMPROVEMENT
[]OTHER
❑DEMOLITION
❑ FOOD SERVICE
t
r.sn
PLUMBING PERd.11T _.�' I FEE
PERMIT ISSUANCE si
ALTER - BRAIN & VENT -WATER (BA)
BACK FLOW PROTECT DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
��FIXTURES - PER TRAP
fdAFR lig.YS iM I INCA OU'FLE: S
WASTE IMTRCE17OR
GREASE IRAI'
SEWER -SANITARY-STORM EA, 20e, IT.
WATER HEATER WNENTXLECTR
WATER SYSTEM/ SEATING
WATER SERVICE
NEW RESIDENTIAL PLML SQ. ET
MECHANICAL PERMIT I FEF.
PERMIT' ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER I0,000 CFM)
EXHAUST HOOD (W/DUC'T
HEATING UNIT (TO 100.000 BTU)
HGTING UNIT (OVER 100.0)(11 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COM(' (3HP OR 100.000 RTU)
BOILER - COMP (OVER 10)(1010 BTU)
AIR CONDITIONER
NI:N' RESIDENTIAL MECH. SQ. PT.
OFFICE _ (L
SQ. FL FLOOR AREA $/SQ. FT
VALUATION
STORIES 'TYPE CONS rRUC1'101
DEC. GROUP APN
BUILDING DIVISION PEES
PLANCHFCK FEE
ENERGY FEE
GRADING FEE
SOILS FIE7
IAN An PNU
'Date RcceiPll
CITY ur uurrisimi
BUILDING FEF,
SEISMIC PEE
ELECTRIC FET:
PLUMBING PH 9 /G
MECHANICAL. Flit: /Y
CONS'T'RUCTION TAX
HOUSING M11 MA'HON FEE
PAID
Dam Rcuuptl
DATE