30502APPLICANTTO FILL IN INFORMATION WITHIN RED
DIVISION APPLICATION/PERMIT
av e...r".r a i_," -
BALL POINT PEN
CONTAC,. PHONE:
/J - 1 7� ❑ Consultant Fees Paid by Applicant (Initial)
1 hereby off. that 1 .m licensed under provisions of Chapter 9 (commencing
OZp with Section 7030) of Division 3 of the Business and Professions Code and my license is
nfull fame and ef➢c
(mss#U' LicenseClass Lit.# 3 ff6.3G/
Contrn,.n,rl0 fti_N_ wica
Ito ARCHITECT'S DECLARATION
t� Z 1 understand my plans shall be used as public records
IOTY.I ELECTRIC PERMIT I FEE I
OWNER -BUILDER DECLARATION
6 I hereby affirm that I am exempt from the Contractors License Use for the
L U following reason. (Section 903 L5, Business and Professions Cade: Any city or county
which =quires a permit to consuuct, alter, improve, demolish, or repair any stmcmre
m.i
man, mits issuance, .Im requires thmpplicam fids such permino file unigned smmmem
} dist he is licensed pursuant to the presidiums of the Contractor's License Law (Chap=s 9
a0 (commencing with Section 7000)of Division 3of the Business and Pmfesomas Coiledca,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
on Section 70315 by any applicant for a permit subjects the applicant a civil penalty of
Oour nine than five hundred dollars ($500)
C 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and are mundane, is not intended or offered far We IS.. 7014, Business
3 and Professions Code: The Contractors 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 improvement am not intended or offered for
sale. If, however, the building or improvement is sold within one year incompletion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
C 1, as owner of the property, am exclusively contracting with licensed contractors to
conswet the project (Sec. 7044, Business and Professions Code:) The Contractor's In.
came law does not apply to an owner of property who builds or improves thereon, and QTY,
who contracts for such pmjmts with a commissions) licensed pursuant to the Conuacmrs
License Law.
C I am exempt under Sec. ,B& P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decelerations:
C Ihave and will maintain a Certificate of Canscnt to self-insumfor Worker's Cooper.
sadon, as provided for by Section 37M of the Labor Code, for the performance of the
ark for which this permit is issued.
.I have and will maintain Workers Compensation Insurance, as required by Section
3 Wof the Latour Code, for the perfomwnceof the work for which this permit is issued.
My Work Com ensatio umnce Gunder and PolicynWn� ap
C.rticr: Policy No.: A/c
CF.R11CAT s OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ohie section need not be completed if the permit is bound hundred dollars ($100)
or Idi
1 certify that in the performance of the work for which this Permit is issued. I shall
no, n
employ any person in any mune, so as to became subject no the Worker' Compen-
0z cation Laws of Celifmnia. Dale
yyP 0 Applicant
qy NOTICE TO APPLICANT If,atkr making this Cenilica= of Exemption, you should
F^ ; become subject to are WorkeYs Compensation provisions of the labor Code, you must
Wfruit. da comply with such Provisions or this pemut shall he deemed invoked.
a
U z CONS
stthe isaconNLIt.NDINGAGENCY
U averts
which
thi thauhe=isuconswni097,agency for Performance of
� f-' the work for xhich this pemdt is issued (Sec. 309). Co,Civ. C.)
C U Lenders Name
4L1 Lender's Address
4 1 certify that 1 have read this application and state that the above information is
TA correct. I agree to comply wit all city and county ordinances and state laws relating to QTY,
U z 'building construction, and hereby auth Trim representatives of this city to enter upon One
above-mentioned property for inspection puryose5.
(We) agree to save, indemnify and keep ha=tless the City of Cumnino against
liabilities, judgments, costs and expenses which may in any way aecme ugailt said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicant/Con motor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcup..I s,am or handle humrdons material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
E] Y. f-1 No
Will the applicant or future building occupant use equipment or devices which
emit bargaining air cor tan ii ndis as defined by the Bay Arc. Air Quality Management
District?
❑Yes CNo
1 have read the harardous materials mquircivents under Chapter 6.95 of the Calt-
fomia Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that if the
building dao not currently have a tensor, than in is an, respunsibilir, to ro fy the occupant
of the replircmenw which must be met prior m or. of. Certificate of Occupancy.
Owner or authodia d agent Dale
PERMIT ISSUANCE
APPLIANCES - RES
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FI%TITRES
NEW RESIDENTIAL ELECTS SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN &
DRAINS- FLOOR, ROOF, AREA. COND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4 (EA)
GREASERNDUSTRLWASTE INTERCEPTOR
GREASETRAP
SEWER- SANITARY- STORM EA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYSTHMffREATING
WATER SERVICE
NEWRESIDENTIALPLML SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
AITERORADDTOMECH.
AIR HANDLING UNIT (TO In." CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUC)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,0010 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR I 011,lM BTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECII. SQ. FT.
OFFICE
FEE
JOB DESCRIPTION
._._.....-.30502
NITARY NO.
APPLICATION SUBMITTALDATI
❑PLUMBING RE -PIPE.
'C MULTI -UNIT
2 w? CL I
NIC
MODIFICATION
CONTROL#
C1 CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIR C3 DEMOLITION
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
❑
❑ ❑ M
JOB DESCRIPTION
RESIN
CSFDWL
❑KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE.
'C MULTI -UNIT
❑STRUCTURAL
MODIFICATION
C INTERIOR
C1 CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEUREPAIR C3 DEMOLITION
DOTTER
COMMERCIAL•
CNEWBLDG/ADDITION ❑DEMOLITION
[]TENANT- ❑ FOOD SERVICE
IMPROVEMENT
POTTIER
// SQ. FT FLOOR AREA SISQ. FT.
Y A 10
pro
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt as
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt #
TOTAL:(