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A fLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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�- I In o c -e CITY OF CUPERTINO- BUI LDINC DIVISION / a
Contra oesNa . q Lic.No: APPLICATION / PERMIT _ l
BUILDING-ELECTWCAL PLUMBING-MF,CHANICAL CATEGORY CONINOL M
Arc tied/Engineer. Llc. No:
Address:
LICENSED CONTRACTOti'S DECLARATION v
,hereby
affirm that 1 am licensed under provisions of chapter 9 (commenc
Ing with Section 7000)of Division 3 of the Business and ProfessionsCode, and m1
license 1s In full force and effect.
License
a C LIC. e
Dale to Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 70315, Business and Professions Code: Any city or
county which requires a permit to construct, alter, Improve, demolish, or repair
any structure prior to its Lwuance, also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and Professions Code) or that he Is exempt therefrom a nd
the basis for the alleged exemption. Any violation of Section 7(1115 by any
applicant fora permit subjects the applicant to a civil penalty of not more ilwn
(ave hundred dollars (500).
E] 1, as owner of the property, or my employees with wages as their sok
compensation, willdo the world and the structure Is not Intended or offered for
kaho
le(Sec 7044, Business and Professions Code: The Contractors License Law
es not apply to an owner of property who builds or Improves thereon,and
does such work himself or through Ns own employees, provided that such
improvements are not Intended oroffered for sale. If, however, the building or
improvement is sold within one yearof completion, the owner -build er will have
th rden of proving that he did not build or Improve for purpose of sale.).
4 as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044„ Business and Professions Code:
The Contnaoet License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pknjects with a
coactors) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B & P C for this reason
I (hvaer Date _—
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that 1 have a certificate of consent to self -insure, or a
certificate of Workers Compensation Insurance or a certified copy thereof (Sec.
3800, Lab Q
I'olky Y
Com ny
Wzyi ied copy is hereby furnished.
CertUaed copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMI%NSATION INSURANCE
(This section need nut be completed If the perndt 4 for one hundred dollars
($IOU) or less.)
1 certify that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the
orkers' Compensation Laws of California. Date
+ppit
cant
NOTICE TO APPLICANT. If, after making this CertUkAte of Exemption, you
should become subject to the Workers'Compensatbn provisions of the Labor
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
l hereby affirm that there Is a construction lend lag agency for the perform
ance of the work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
l certUy that 1 have read this appBcalbn and toile that the above In(ormatlon
is cornett. I agree to comply with all city and county ordinances and state laws
relating to building consinuslon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, jadgments, coats and expenses which may In any way accrue
agalnslVillily in coasea.Whce of the granting of this permit.
grfature of App11c.3nhCoAKdur Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Section 25532(a)?
0 Yes n No
Will the applicant or future building occupant use equipment or devices
which emit hazardous air cuniaminanis as defined by the Bay Area Air
Quality Management District?
4 Yes No
have read the bazar nus materials requirements under Chapter 6.95 of
the California Health k Safety Code, Sections 25505, 25533 and 25534. 1
understand that If the building does not currently have a tenant, that It Is my
responaibduy to acetify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANC IS RESIDI:NI'IAL
PANELS
OVER 1000 AMPS
SIGNS ELECTRICAL 1 ov '%
SI'ECIAL CIRCUIT/MLSC
T rMP. METER OR POLE INST.
POWER DEVICES
SWM MINC POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ.Ff.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN k VENT - WATER (EA)
BACK FLAW PROTECT. DEVICE
DRAINS ROOK, ROOF, ARIDA, GOND.
FIXTURES- PER TRAP
GAS EA. SYSTEM -1 INCA OUTLET'S
CAS EA. SYSTEM -OVER 4 (FA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER-SANITARY-S'I.ORM EA, 2WF1'.
WATER HEATER W/VFN'f/ELECTR
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.Ff.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT Cf010.000 CFM)
AIR HANDLING UNIT (OVER 10,000CI--M)
1.7(HAUS f I IOOD (W/DUCT)
HEATING UNIT (TO IOU,OW BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU
NEW RESIDENTIAL MECH._ SO.Ff..
OFFICE COPY
TOTAL:
FEE
BUILDft INC PERMIT INFO
JOB DGSCRBrrION --
SQ. Ff. FLOOR AREA S/SQ. n%
FEE SUMMARY
SANITARY Y_ N_
RECl9'1' It
SCIMOOL TAX Y N_
RECFIPf M
PARK FEE Y N
RECEIPT _
BUILDING DIVISION FEES
PLANCHECK FEE
PAID
Date Recei�tN
ENERGY FEE Y N
PAID
Date Receipt#
TOTAL:
B --
SEISM IC FEE
ELEcrRIC FEE _
FEE PLUMBING FEE _
MECHANICAL FEE
-rocs PAID:
Date Recei til
SUBTOTAL:
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
_ Date Receipttl _
TOTAL.
ISSUANCE DATE
ISSUED BY:
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