31494APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE
CITY OF CUPERTINO ' - e
BUILDING DIVISION APPLICATION/PERMIT 1
PHONE:' -
e
)INT PEN ONLY
BUILDING -ELECTRICAL .'
'1,UMBINf: - MECHANICAL
ING PROJECT IDENTIFICATION
AE: LICI
-❑ Consultant Fees Paid by Applicant (Initial)
• Z 1 hereby affirm that I um licensed under previsions of Chapter 9 (commencing
Op with Section7000)of Division3 of We Business and Professions Code,md mylicense is
in full form end a 1.
F U� License C s _ V
sn y Dam Can DEcLA .
ANdell thermal
h rat DELLA TON
X O Z I undersmnJ my plans shell tc ucetl es public reards
OZ
b+4Wcens
Lied Professional
gm; OWNER BUILDERDECLARATION
,LLL'"' Q 1 lmrcby union that 1 am exempt item the Contractor's License Law for the
3 6 following mason. (Section 7031S, BaritwA and Professions Cada: Any city or county
a which requires a permit to rnmme, alter, improve, demolish, or repair tray swcwre
prior to its issuance, also requires me applicant for such permitto file a sighted statement
Qthat he is licensed pan uanuothe provisions of The Conlmcon" License Law (couple,9
(commencing with Section 7(mal of Division 3 of the Business and Professions Cpdc) nr
d q o
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
YX1I ILSection 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of
} not more than five hundred dollars ($500).
OD 1, as owner of the property, or my employees with wages as flair sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, lousiness
% and Professions Code: The Conmaem's License Law does not apply toan owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are net intended or idlbped for
sale. IL however. the building or improvement is sold within one yam of completion, the
caner -builder will have the burden of proving that he did not build or improve for Pur-
i pose of sola).
❑ Las'owner of the property, am exclusively contracting with licensed contractors to
construct The project (Ser. 70,l4, Business and Professions Cede:) The Contractors Li-
cense law does not apply to an owner of property who builds or improves thereon, and QTY,
who contracts for such projects with a cmnruclons) licensed pursuant to the Comme or's
Liceme Law.
I am exempt mater Sea. ,B&PCmrthismm n
Owner Dom
ORKER'S COMPENSATION DECLARATION
Is, Ihereby affiW rm tinder penalty ofperimy one olThe following declarations:'
❑ I have and will maintain a Certificate of Comentto self-inmre for Workers Compere
mien, as provided for by Section 3700 of Ne Labor Code, for the perfommuce of the
work for which this permit is issued,
have and will maintain Workers Compensation Insurance, as required by Section
3 ofuhe Labor Code, for the performance ofthe work for which this permit is issued.
My Work do In�aerand Policy-a�9�f �ty�
Cartier. ,T{-u•��Policy No.: ,A-f�b�
CERTIFICATE OL' EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE
(This section need not he completed if the pemiil is foronc hundred do'llum ($1 W)
aNess.)
I candy that in the performance of the work for which this permit is issued, I shal l
not employ any Person in any manner as In become subject m the WorkersCompen-
z sm ion Laws of Cal ifomia. Data
ZApplicata
..tea NOTICE TO APPLICANT: If, offer making Ills Certificate of Exemption, you should
become subject 10 the Worker's Compensation provisions of the [.shot Code, you must
{$1 forawith comply with.such prubisions or this permit shall he deemed revoked. I
z CONSTRULTIONLENDINGAGENCY
V Q thereby affirm lhanhere isnconswnion lending agency fnrthc pedbrmance of
WF the work for which this permit is issued (Sec. 30)], Civ. CJ
0 U Lenders Name
D-1 Lenders Address
y 1 cenify Ihm I have real this application and some that the above infor....ion is
to coma. I rupee to comply withal] city and county ordinances and slate laws relating to QTY
V z building construction, and hereby umhormnaposenmtives of this city to enter upon the
uMwc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, coves and ns
eapees which may funny way .cane against said Cily
in construction of the gmrding of this permit. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITHATL NON -POINT
SOUI�GyEGULATIONS. n -' „
HAZARDOUS MATERIALS DISCLOSURE
. Will the applicant or future building occupant store or handle hmurdous material
as defined by the Cupertino Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Sectlm 25532(a)p
DY. ❑sm
Will the applicant or future building occupant use equipment or devices which
Jmit hazardous air contaminants as defined by the Bay Area Air Quality Management iana?
❑Yes E] No +
1 have mail the harardous mmenols mquiremems under astute 6.95 of Nr. Cali.
hands Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand Ibal if the
building docs not cannot have a tenant, ohm it is my responsibility to notify The occupant
of the requirunems which must he mel prior In Issuance of it Cer ifcam of Overprint,
ELECTRIC PERMIT FEC
PERMIT ISSUANCE
APPLIANCES -. RESIDENTIAL-
PANELS
UPT02MAMPS /
201-1000AMPS
OVER I" AMPS '
SIGNS HUiCIRICAL
SPECIAL CIRCUIT MISC.
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC a
06METS- SWI 'PCHIES -FIXTURES
NEW RESIDENTIAL ELEC1t SQ
TOTAL:
PLUMBING PERMIT F,
PERMIT ISSUANCE
AT.'] ER - DRAIN & VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROUP, AREA, COND.
FIXTURES - PER TRAP
GAS- EA SYS'T'EM -1 INC!4 OUTLL'TS
GAS-EA.SY$TEM-0VER4(EA)
GREASHIINDUSTRLWASTEIN'I'E•NCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER THEATER WNENT/ELECfR
WATT SYS'FEM/I'REATINO -
WAT1IR SERVICE
NEW BESIDES ITAL PLMIL SQ, Pf.
MECHANICAL PERMIT
PERMIT ISSUANCE .
ALTER OR ACETIC MECH.
AIR IIANDLING UNIT (TO IQ(XM CFM)
AIR HANDLING UNIT (OVER 10,00X1 CPM)
EXHAUST HOOD(W/DUC)
BEATING UNIT TO 100,000 BTU)
I[EATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
BOILER- COME (OVER I00,00) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. IT.
OFFICE
ren
-SANITARY NO. AT
r
1 NIC
O r
BUILDING
31494,
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
[] KITCH17N REMODEL.
DADDITION
❑ PLUMBING RFPIPE
11 MULTI -UNIT
DSTRUCTURA. s
MOD1171CATION
D INTERIOR
D CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMODEUREPAIR
[]DEMOLITION
[] O'FHER
COMMERCIAL
❑NEW BLDG/ADDITION
El DEMOLITION
❑TENANT
[]FOODSERVICE
IMPROVEMENT
[]OTHER
.. TOTAL.
SQ. FT FLOONAREA EI'.
A i D,
041?
STORIES
PAID �1
Date Receipt Or
'TOTAL: (,
Ip
ISSUANCE DATE ,
BUILDING DIVISION FRES '
FEE
E
!GRADJ!NG�E
PAID
Data Receiptp -
.. TOTAL.
BUILDING FEE ' [-
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBINGFEE
MECHANICAL ITEM
CONSTRUCTION TAX
HOUSING MITICIAT10N FEE j
PAID �1
Date Receipt Or
'TOTAL: (,
Ip
ISSUANCE DATE ,