29060APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO - BUILDING-ELEGHRICAL 1' PERMIT NO. O O
BUILDING DIVISION APPLICATIONIPERMIT ar
PLUMBING MlicnnNlcnl.
r onnf-T muNTsel r 1IT"N
SIR
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under pmvisions of CIONO9 (commencing
witectionWonof Division 3 ofthe Business and Professions Code, and my license is
S
In full force anile r '
Lic.k 0 a
ate Cnnuamor /M
A
DIiCLARATION I understand my plain shall he used as public recoNs
shallhe into
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BUILDING PERMIT INFO
El MULTI -UNIT
BLDG
❑
3 W
Licensed Pmfesmional .
El INTERIOR
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OWNBR-BUILDER DECLARATION -
C a
D Q.F
ON
1 hereby affirm that I am exempt from the Contractors License Low for the
following reason. (Selllna 7031.5, Business and Professions Cale: Any city or county
which requires a permit to consent. alter. Improve, demolish, or repair any auction,
prior to its issuance, also requires the applicant for such pe.it to file a signed statement
that hero licensed purmmnuo the pownionsofthe Contractor's License Law (Chnpter9
C1 DEMOLITION
'ter^
Z p.,
q Z Q
L.F.
Vand
Lar
essenJPn, Any violation
(commencingrt,b Semfrown and of Divisi fr the
that he is exempt Nerefmm and the basis for the alleged exemption, to Anyil penalty of
Section 703LSby hundre lieu][ ($50 mrit subjects the applicantmncivil penalty of
09
not more then five hundred dollars y employees
❑ L o the work, the property, or my of intended wi0 caages red for alei(Sec. compensation, nosiness
Business
will dathewons andthe he chum Contractors Limm proffered faro, apply
Professions Calc: The Contractors License Low data mol apply In if owner of
property who Fnildse., or thereon, nr through
ural whornes such work hanoiled
IMPROVEMENT
❑ OTHER
of
i intended or offered for
provided m such improvements are n
his awn employees, provided that
e
however, the building nrimprnvemem is sold within ane year of completion. the
sale. n
mer -builder will have the beNen alproving Ihm he did not build or intpnrvc fnr par
mer-
pose of sale.).
El 1, as owner of the property, am exclusively contracting with licensed contractors m
constmct the project (Sec. 7044 QBusiness and Profes,ions Code:) no Cmionamr's Li-
u law dues not apply to an owner of pcepeny who build or improves thereon, and
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who mmmcts for such projects with o conunctons) licensed par ona m the Commemr's
License Law.
❑ I am exempt under Sm. . B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under Penalty of pujury into of the following Jectmea, on,
❑ P have and will maintain a Certificate of Consent o self-insurc for Worker's Compen-
swim, as provided fnr by Section 3710 of the Labor Cede, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37Mv!d Labor Gde, for the perfomione of the wnrk for which this parol is issued,
M arke=es Gn6�nspli�nsumnce comer and Policy number are:
•
iii !J Policy Nn.:
CERTIFICATI3 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplered if the permit is foromhundrN dollen (SIM)
or less.) -
I certify that in the perfmmanc'e of the work Tor which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers Compen-
0dation
O
Law, of Califim.it. Dane
Applicant
NOTICE TO APPLICANT: If.after making this Certificate of Exemption, you should
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become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions m Nis pernitshall be deemedrevoked.
CONS 'IRUCfION LENDING AGENCY
V O
ky.
- l hereby affirm that there iso conswnion lending agency far the perfenamse of
the work for which this pumit is issued (Sec. 3007, Civ. C.) '
O ULenders
Name
Lenders Address
{11
0correct.
U /y
1 cemly, that I have read his application pad state that the above infnrnnuien is
P agree to comply with all city and county ordinances and state to ... clating m
building construction, and hereby sullofire representatives of this city to enter upon the
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.mm-niemloned pmpcny fnr Inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Cupertino against
Iiabilities,judgments,casts and aspens which..,many way meneagainst sail Ciry
n comequenoa oft
'ertnit.
APPLICANT UNDERSTANDS .. D WILL COMPLY WITH ALL NONPOINT
r [ HAZARDOUS MATERIALS DISCLOSURE
Will Phu applicant or future building occupant stareor handle hazardous mamma
as defined by the Cupenim Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
Dyes 0 N
WIPP the applicant or future building occupant use equipment or devices which
(emit haurdm n, air communism, as defined by the Bay Area Air Quality Management
District? '
❑Yes 7 N
P have rend the barumous material, requirements under Chapter fi 95 of the Cal
fomia Health & Safety Code, Sections 25505, 25533 and 25534 1 understand tam if the
building does not currently have a tenant, that it Ls my re,ponslbllhy to notify the occupant
of the requirements which most he met prior to issuance of a Certificate of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES- RFSIDEMOAL
PANELS
GET'an AMPS
201-10MAMPS
OVER UXOAMPS
SIGNS ELECTRICAL
TEMP. METER OR PULE INST.
POW17R DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXT
NEW RESIDENTIAL ELECTS,
PLUMBING
PERMIT ISSUANCE � 11
ALTAR - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
FIX1URES-PHR'1'RAP P.'
GAS- PLA. SYSTEM. I INC. 4 OUTLETS y
GAS - F.A. SYSTEM -OVER 4 (EA)
OREASFJINDUSTRL WASTH INTERCEPTOR
GREASETRAP
SEWER -SAMTARY-STORM EA. 200 PT.
WATER HEATER WIVENT/ELECTR
WATER SYSTEMaREATING
WATER SERVICE
NEW RESIDENTIAL PLMB, SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MELD,
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING USTT (OVER 10,001)(717M)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I01l(00 BTU)
VENTILATION FAN (SINGLE REBID)
BOILER—COMP CHIP OR 1(0,000 BTU)
BOILER—COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
FEE
❑I
❑ KITCHEN REMODEL
❑ADDITION
BUILDING PERMIT INFO
El MULTI -UNIT
BLDG
❑
ELECT, PLUMB
❑
MEC
❑
RFSIDF_NTIAL
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
C1 PLUMBING RE -PIPE
El MULTI -UNIT
El STRUCTURAL
MODIFICATION
El INTERIOR
C1 CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMOD LIREPAIR []DEMO LITTON
❑ OTHER
COMMERCIAL:
❑ NEW BLDG/ADDITION
C1 DEMOLITION
❑TENANT
❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. MOOR AREA $ISO. FT.
PgAID
DEC 141995
C11Y UI- UUPLHIINC)
I BUILDING DIVISION MRS
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dam ,poem-#
TOTAL:
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING IEE
MECHANICAL P.
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
TOTAL:( ( ISSUED BY: "11� 1
OFFICE'