S 0275APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILANC. -ELF'f ill CAI, PERMI'I'No. '7
BUILDING DIVISION APPLICATION/PERMIT rING PROIECT?CUNTIFIC S 0 2 1 5
"amL nING PRQIRLRT IDIiNTINICA'1'ION f.' t�
CONTACT.. I rrss,.�gvr�.
�C45r, +
LICF.NSIeD CONT RACI OR'S DECLARATION
I hereby affirm that I uit, licensed under provisinns of Chaper 9 (enm andudog
X02 with Section 7000) of Drsomn Sol the ,o
vnd Pmfeninns Cale, nnJ lay li(eroe is
F ly in full furce and effect.
Q, U V Licence Clan Lie. p
Inum—Cmartwon-
ARCHITECT I DECLARATION
on
Z 1 makotund my pla shill be used as public rccaMa
.,kc Licensed Pmm,00nal
i OWNER - BUILDER DECLARATION
0.� I herchy uEirnt that on escuum rrum the Conluul.f, Liccnae Law for the
O L U following reason. (Section 7031 .5, Business and Profession Cole: Any city or county
W ON which require, u permit to construct oher. improve, dcmob,h, tit repair any stnware
�' prior to its issuance, also requires the applicant bor such permit to file a signed statement
}
list pursuant o
vt he is licensed pursuano the provisnx of the Cono license cense Law(Chapter 9
04 (commencing with Section 700(q of Division 3 of he Business and Profession, Code) or
X°m that he is exempt therefrom and the basis lot the alleged exemption. Any vlohainn or
U�y
Section 7031.5 by any upplicantfor a Permit subjects the applicator o a civil penalty of
[. not mare than five hundred dollum S500).
O ❑ I, as owner of the Pm,ny, or my employees with wages as their sale compen,ilmC,
t1s will do the work, and the structure is not intended oro0'ered forvle(Sce. 7044, Business
W �" and Prnfessionx Code The Contractor's License Law does not apply tat an owner of
u property who builds m improves thereon, and who does such work himsellbnhrough
his own eniploycea, provided that such improvements am not intended or offered for
sale If hurvece, the building of improvement i Id within n y if emapfictimi. the
owin,-leadder is dh have did burden 1 proving d , he did not h Id a, unfar d d, Pr -
fal )
feral 'he p P rtB, am exclusively contracting n t with I d o tr t to
nh Project S c. 7014 B d ref
Cad,) The Commoor, Li
an owner of propery who on Ids oramproves thereon, i d
who contracts for such projects with a comrecmr(s) licensed pursuant u, the Cannot
Ucene low.
I and exempt under Sac. - .1) &P C for this ream.
t WORKI?R:S COMPENSATION14CCLARA'I'10,
•, l hereby u0lnn under penalty of perjury one of the 10Hdwing dminration
I have and will maintain eCertificate of Continuo Civic, inre far Workers Compen-
' ocean, ex ProviJW for by Sechnn 3711U nl'thc huMn Cale, far the performance of Thu
work for which this permit is issued.
[-1 1 have and will mainamn Workers Compensation Insurance, as m care 1 by S• lion
3700 of the Lmbmr Cale, for the pe forme ace of the work for which this Permit is issued.
My Workers Compensation Insurance carrier unit Policy number are:
Carder: Policy No.:
CERTIFICATE OF EXEMPT ]ON PROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is 1'onme hundred Julien ($100)
_ nr less.)' -
1 certify that in the performance afford work for which this permit is issued, I shall
nor employ any person in tiny manner so as to hecomn subject m the Workers' Compen-
Z mion Laws of Calihsmia. Data
Z 2 Appllcoal m
Z NOTICE TO APPLICANT: IC after making this Certificand of Exenmption, you should
a ; hecome.subjam to the Worker's Cmntpcnsminn provisions of the Labor Cade, you and
forth% ith comply with such provisions or this permit shall be donned revoked.
z CONSTRUCTION LENDING AGENCY
U 0 thereby of rat that there is a co ithictlon lending agency for the perfornaace of
U. F the work for which Ois permit iv lowed (See. 3097, Co, C.)
O ULenders Name
U Lender's Add....
f..I fy 1 certify that I have read this application and suite that the art information is
4 correct.I agree to comply with all city and county ordinances and ante laws relating to
Z, U G building construction, and hereby authorize representatives of this citym enter.,. the
above -mentamed properly for inspection purposes.
(We) agree m save. indemnify and keep harmless the City of Cupertino against
liabilitiec,juhou,n ,tasteand expenses which toy in any way accrue tam asaid City'
onscquence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupam sore or handle hazefdous macoal
as disband by the Cupertino Municipal Code. Chapter 9J2. and the Health and Safely
Grade, Section 25532(x)"
❑Yes E] No
�Will the applicum or future building occupant use equipment or devices which
y Inad hamrdou.c air contaminants as defined by the Bay Arco Air Quality Management
District?
❑Yes ❑No
I have read the hazardous materials ruquircumms under Chapter 6.95 of the Cali
romin Health & Safety Cads. Sections 25505, 25533 and 25534. 1 nourishing] that if the
building does no curenry haven tenant, that It is my respoavibdity m nrnify the occupant
Of the requirements which must be met prior to issuance of a Ce tificme of Occupancy.
TIC
❑ Consultant Fees Paid by Applicant (Initial) 4 r_� ..
.t • EI.EC'rRIC PliRMI'f �, / ,'', •, :,r
PERMIT ISSUANCE EC
APPLIANCES - RESIDENTIAL
PANELS
UP] 'O 200AMPS
SIGNS ELECTRICAL
SPECIAL. C1RCUT,MISC.
TEMP, METER OR IY)LE INS'('.
POWER DEVICES
SWIMMING 1'001. FLECTRIC
OUTLETS - SWITCHES - FIXTURES
SO r.
•'t'�t !PLUMBING PP.klkil
PERMIT ISSUANCE7
ALI ER- DRAIN &VHN'r -WA :; ( )
BACK PLOW PROTECT'. DEVICE
DRAINS - FLUOR. ROOF, AREA, CONO.
FIX'I'URIiS -1'ER I RAPTRAI'
GAS - HA, SYSTEM -1 INC.4 OUTLI r S
GAS - EA. SYSTENTOVER 4 UHA)
GREAS DINGUS'I RL WASTE INTF.RCHMGR
GREASETRAP
SEWER- SANITARY -STORM P.A. 200 FI'.
WATER HEATER WNENTIELECTR
WATER SERVICE
NEW RESIDENTIAL PLMII. SQ. PI'.
` t; MECHANICALPERMIT''
r
PERMIT ISSUANCE
ALTER OR ADD TO MECII.-
AIR HANDLING UNIT' (1'O 111,11110 CFA)
AIR (IANDLING UNIT' (OVER 111,0110 CNM)
EXHAUST HOOD IW /DUCT)
I]RATING UNIT (TO blo.orat if rut
I IENIING ONIT (OVER 100,000 B'I'Ill
VENTILA'OON PAN (SINGLE RESID)
BOILER - COMP OTIP OR 150.000 BTU)
BOILER- COME (OVER 100010BIU)
AIR CONDITIONER -
NEW RESIDENTIAL MECH. SQ: FT.
NIC fNTI-
0
III ALDING MIRM IT INFO
BLDG ELECT PL11M11 MIiCH
JOB DESCRIP'T'ION
DWI.
❑K ICHENRI?MODEL
❑A DI'HON
El PLUMBING RE -PIPE
❑MUL'I'[ -UNIT
❑STRUM URAL
PAID
Date Bell I k
MODIFICNI'[ON
El INTERIOR
ED CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
[_1 PATH REM D'IAREPAIR ❑DI :MOIAI'ION
❑CMIER
COMMERCIAL:
❑ NEW It
❑'1'F:NA
IMPROVI?
❑ OTQ Ij-}�_
IQ. 14. FLOI
too k
;FEE• 3 (Q bLJ
❑ FOOD SHRVICH
08 ar,_
SSQ. Em
MT:CHAN -ALFEE
CONS SFR IC'I'ION TAX `
HOUSING M At ION TEE
PAID
Date Receipt#
III TOTAL:
ISSUANCE DATE
r
1i v
ENERGY PIiEL
GRADING P
SOILS ME
PAID
Date Bell I k
IT
FEfi',_
BHCH N(
sptsaau tau:. '
SSQ. Em
MT:CHAN -ALFEE
CONS SFR IC'I'ION TAX `
HOUSING M At ION TEE
PAID
Date Receipt#
III TOTAL:
ISSUANCE DATE
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