S 0207APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUD,DING - ELECIRICAI,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL
BUILDING PROJECT IDFNTIFIL'ATION
PU§lI T NO,
\ n 0
V OL
ILDING ADDRESS:
e -D�)
SANITARY NO.
APPLICATION SUBMITTAL DATE
WNER'. NAM PHONE:
CONTRACTOR'S NAME: LIC NO
N/C
❑
CONTROL#
RCHITECTIENGINEER: LIC NO:
ADDRESS:
coNTgCI': PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT' 'LUMB MECII
thatI a CONTRACTOR'S DECLARATION
I hereby 000rm tent I am Eansw under ndP oona ons Care, 9 Rm licensers
with Secreand Oof Division anfthe Business and Professions Care, and my licenseis
in full force and eRea,
License Class Lie. It
Dam Coannmr
ARCHITECTS DECLARATION
ij l understand my plansshall hsmadaspubl'mmmrds
]
QTY ELECTRIC PERMIT FEE
JOB DESCRIP ION
RESIDENTIAL
GSFDWL OKITCHENREMODUL
❑ADDITION ❑ PLUMBING RIsI-PIPE
GMUISI-UNIT' 05TRUCTURAh
MODIFICATION
C)INTERIOR ❑CHIMNEY REPAIR
IMPROVEM1iNT E3 SWIMMING POOLS
❑ BA'I'li REMODIiURI iPAI DEMUhITION
OOTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS -
UPT02t01AMP5
t1 L¢enscd Pmfasinnal
OW NELDER DECLARATION
aj
I batch,hy off rte ohm 1 sin exempt from the Contractor's License Law for the
J fallowing reason. (Section 7031.5. Business am Professions Code: Any city or county
which requires a Permit to construct, alter, improve, demolish, or repair any saucture
,nano its issuance, alsonamires thcapplicant 0nsuch pamn,Infileasigned smmmem
E that he is licensed personal to Ne provisions afthe Contractors Licenve Law (Chapter Y
] (commencing with Section 7") of Division 3 of the froonessmil Profcnsions Code) or
p that he is exempt therefrom and the not, lin the alleged exemption. Any violation of
n Section OWLS by any applicant file o Partial subjects the appiicanrto a civil Penalty of
not more than five hundred dollan($5M).
01, as owner of the pmpeny, or my employees with wages as their sole compensation,
will do the work, and the snaltme is not intended or oaemd torsade (See. 7044. Rosiness
and Professions Code: The Contmmors Lianas Law does not apply to an owner of
property who huilds or iinpraves thereon, and who docs such work himself or Ihmugh
his own employees, provided that such improvements arenot intended nr offered for
sale. If, however, the building or improvement issoldwithinone year nfrompinion.the
coscar-milder will have the burden of proving that he did not build tar improve for pur-
pose of sale.).
0 I, as owner of the property, am exclusively contracting with licensed contractors to
tmtmct the prnject (Sec 70,14, Business and Professions Cade) no Contractor's Li-
cance,Lowd«, not apply to an ownerofpropeny who buiddaorimpteve%n,ereon,and
who contracts for such projects with a communist licensed pursuant m the Cmentemes
License Law.
Ej 1 am exempt under Sec , N & P C for this reason
201-10MAMPS
OVER IIXXIAMPS
SIGNS ELECTRICAL
SI'[CIAI. CIRCl11T/MISC.r,—
TEMP. METER OR POLE INST.
COMMERCIAL -
0 NEW BLDG/ADDITION 0 DEMOLITION
OITNANT ❑ FOOD SERVICE
IMPROVEMENT
0 OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELEC'M
SQ. FT. FLOOR AR LA
D
��� 25 an
5/SQ. FI.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
Owncr Date
Vi VpLUATI(IN
�VrCh))NU
WORK. SCOMPEN, IONDFCLARA N
1 hereby affmt under penalty of perjury one of the following declaration.:
❑ l have and will maintain a Certificate of Consent to self -insure for Workers Compete
cation, as provided for by Section 37M ar the Labor Gude, for the perrnrmance of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Lowr Cade, for the pmhamince of the work far which this permit is Issued.
My Worker's Compensatinn Insurance carrier and Policy number are:
Carries Policy No.:
CERTIFICATE OF EXEMPTIONNSFROM WORKERS'
COMPENSATIONINSURANCE.to
(This section need nm bemmpinted ane peemit is fornnehundreJ dollars (5100)
or less.)
sfth 1.lam for subject
this permit is the Workers Concha-
Toy my thatparan the effoany
not employ any Califon in any manner so az m become subjen m the Workers' Cnmpen-
scion Laws of California. Data
Applicata I
BACK 110W PN(TI'CCT. UIiVICIi
DRAINS- FLOOR, ROOF AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES-PER'rRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
APN
GAS - G. $Y$'1'lihl-OVF.H J (EA)
GREA51%INDUS'THI. WASTE INTFikCEP1T)R
GREASETRAP
BUILDING DIVISION FEES
PLANCHECK FEB.
SEWER -SANITARY- S'T'ORM EA. 2W FT.
ENERGY FEE
WATER HEATER WNENT/IA.ECI'N
GRADING FEE
NOTICE TO ADPL a ANHp.Wank esf. afterComa i ag mu Cenims of of Exemption, ion, you should
of the Lahr Code, you nun
become subject to the Wnrlers Compensation permit shall
Tonhwith comply with such pmviainns nr this permit shall he damned revoked.
CONSTRUCTION LENDING AGENCY
Iherehyaf0m, that hem N a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ, C.)
Lenders Name
WATER SYSTEM/IREATING
SOIIS IIiE
WATER SIiRVICIi
PAID
Du Recciptp
NEW RESIDENTIAL PLMIL SQ. IT.
TOTAL:
Landers Address
1 certify that l have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building connmctisn, and hereby authorize representatives sf this city m enter upon the
above-mentioned propeny for inspection purposes.
We) agree m save. indemnify cep yo aagainstPERMIT
g y and k harmless the Cit of nits iCty
expenses which may in any way accrue against said City'
liabilities,judgments, granting
in consequence of the gmming of Chia permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
BUILDING
QTY, MECHANICAL PERMIT FEE
SEISMIC
ISSUANCIi
ELECTRI F .F.
ALTER OR ADD TO MEC#.
1'LUMNIN FEIi
AIR HANDLING UNIT (TO 10.00) CFM)
MECHA CAL FEE
AIR HANDLING UNIT (OVER 10,10C) CFM)
CONSTRU ON TAX
Signatumod AppLaant(Cantmeme Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haramos material
nt defined by the Cupertino Municipal Code, Chapter 9.12, and the Hculth and Safety
Code, Section 25532(a)P
OY. No
Will the applicant or future buildin • occupant use equipment or devices which
u
mit hrardousui commonness defined by theBay Area r Quality Management
Dinner?
-1 Yet L] No
I have Head the haandoua materials equirmands under Chapter 6.95 of the Cali
fomin Health &Safety Code, Sections 255(1.5, 25533 and 25513. 1 understand the Have
buildingaces tatcurrentlyhovea tenant thus it is53 rend 255 4.1 mnotifynd occupant
of the requirements which must he met prior a, issuance of a Certificate of Occupancy.
EXHAUST HOOD DVMUCT)
HOUSING MIT 'ATION FEE
HEATING UNIT (TO I KII(III BTU)
HEATING UNIT (OVER ino,ow it rut
PAID
Date Receipt p
VENTILA'DON PAN (SINGLE RFSID)
BOILER- COMP OHP OR Ifq.UUll it
TOTAL:
BOILER- COMP (OVER 100,0M BTU)
AIR CONDITIONER
ISSUANCE DATE^
DRY.
NE RESIUENTIAI. MECII. SQ. FT.
Owner or auNonzed agent Dam
TOTAL:
OFFICE