29790. v
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL . PERMIT NO. 2 9 7 9 O
BUILDING DIVISION APPLICATIONIPERMIT r PLUMBING -MECHANICAL L `4J
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - - •t' - - SANITARY NO. APPLICATION SUBMITTAL DATE
ICA. CAW CAOCI'l
T El
CONTACT:
1 hereby affirm that 1 am Leenscd made, provisions of Chapter 9 mommencing
with Section 7") of Division 3 of the Business and Professions Cale, and my license is
in full force and effect.
Lice/J SO V"14nse Class - Corer _FAzg-• P -
17S
A HIT DECLARATION'
Inndersmnd my plans shall be
M1e used as public records '
'NTRACfOR'S NAME: hIC NO:
ta NIC
EK/� tTEic�Eh/ da
�DRI'SS: ❑'
❑ Consultant Feas Paid by Applicant (Initial) DLDG
C X�
OWNER -BUILDER DECLARATION
6' Q
V
1 hcmby affirm that I am exempt from the Conferees License Law for the
a6
following reason. (Swtion 7031.5, Business and Professions Code: Any city or county
F WO
which nequires a permit to conssmci, aher, improve, demolish, a,rcpnlr any snotom
prior to its issuance, also requires the applicant for such )emit to file u signed statement
}�
ohm he is licensed puma t to thepmvisionsofrhe Contractors License Law(Chapter9
CO(commencingwiNSenion
00007of Division3ophe 11minessand Professions Cale)or
6 y m yv
LL%1 V4
that he is exempt therefrom and the basis for the alleged exemption, Any violation of
Section 7031.5 by anyu,fourt for a pent subjects the applicant to n civil ped lyof
P, }
not mire than five hundred dollars (6500).
6
(]1, as owner of the property, or my employees with wages as their sole munpenodon.
will do the work, and theswcture is not intended or offered for sale (Sm.'a1f4. Business ,1
3
and Professions Code: The Contractor's License Law does not apply to an owner of ' U
property who builds or improves thereon, and who does such work himself or through
hisemployees, provided that weir improv re encs anot intended er offered in,
sale. If. however, the building or improvement is sold within one year of complaion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
you ofsale.). -
Fl 1, as owner of the propeny, am exclusively contracting with licensed contractors m
construct the Frojmt (Sec. 7044, Business and Prefesslons Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and QTY,
who contracts for such pmjecte with a contmctor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for his reason
Owner Date-
WORKERS COMPENSATION DHCLARATION
1 hereby affm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to ulf-inwre for Warkers Cambia-
satlon, as provided for by Section 3700 of the Labra Code, for the performance of the
work forwhich his pennh is issued,
1 have and will neintuin Worker's Compensation Insurance, u, required by Section
3)00 of the Inbor Code, for rhe performance of the work for which this Femur is issued.
My Worker's Compensation Insurance canner and Policy number art:
Canter. Policy No.:
CERTIFICATEOFEXEMPTION PROMWORKERS'
COMPENSATION INSURANCE
Mir smtio. need not be completed ifrhe )amain is (atone hundred out]. BiIIXp
m less.)
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any baro, 'n any mo mo so.Uo ban
eie suhJect to the Workers' Contpen.
O z
satin .uws o f Calf Dn
ill
1 O
• hut i
n
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption, you should
abecome
subject to the Worker's Compensation provisions of the Labor Cade, you must
W
fonhwlth comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
O
I hereby affirm that hen is a consumption lending agency fonhe performance of
fY F
the ..,it for which this )emir is issued (See, 3097, Civ. C.)
Lenders Name
Q U
Address '
WI.enders
I minify Nat 1 have read this application and state that the above information is
LQ
h
cortin. 1 agree to comply with all city and county ordinances i n l,tete laws relating m QTY.:.)
2
building construction. and hereby authorize repmwnmiives ofrhis city it) enter client the
above-mentioned pmpeny far inspection purposes
(We) agao it, save, indemnify and keep hanNeas the City of Cupertino ugahat
ludilities, adgmeriN,costsand expenus which may in any way accrue against said City'
in asequence of the granting of this pennit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGG TIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant or future building occupant score orhandle hazardous co adal
as defined by the Cupertino Municipal Code, Chapter 212, and the Health and Safety
Code, Section 25532nd? -
❑Yes El No
1
Win she applicant or fumy building occupant use equipment or devices which
¢area) hazaNnus air contaminants as defined by the tiny Area Air Quality Management
IDablas o
❑Ycs E)No
I have read the hmanlous materials requirements under Chapter 6.95 of Ne Cali.
forms Health & Safesy Cade, Sections 25505, 25533 and 25534, 1 understand then if the
building does not cunanly have a tenant, that it is my resrymsibility to notify the occupant
of the requirements which must be met prior id Issuance of s Certificate of Occupancy.
Owner or th ttotzed agent Date
ELECTRIC PERMIT
P.RMH ISSUANCE s
APPLIANCES -RESIDENTIAL
PANELS
Up'1'0200AMPS
201-1000AMPS -
SPECIAL Cl RCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES '
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES r'
NEW RESIDENTIAL ELECTR SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF. AREA, COND.
FIXTURES - PER 'TRAP
GAS EA, SYSTEM -I INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4(EA)
GRHASE/INDUS'1'RL WASTE, I N'TERCEPTOR
GRF.ASETRAP
SCWHR- SANITARY -STORM F.A. 203 FT.
WATER HEATER WNENT/ELIiCTR
WATER SYSTEMRREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL P17RMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO 10,1100 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (10 100,000 BTU)
HEATING UNI "r (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (3 HP OR 100,000 BTU)
BOILER- COMP (OVER IOQ0s) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ,
FICE
FEE
BUILDING PERMIT INFO
.MFCFP
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL - >(.11TCHRN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
❑ INTERIOR ❑ CHIMNFY REPAIR
IMPROVEMENT
❑ BATH REMODEIJREPAIR ❑DEMOLITION -
❑ OTHER
COMMERCIALS
ED NEW BLDG/ADDITION 11 DEMOLITION
s ❑TENANT FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ.FT.FLOORAREA &SQ. FT.
p
FEE G ® 10 0
c\\y
STORIES - TYPE CONSTRUCTION
OCC. GROUP AM '
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
Sons FEE M
PAID
Dare ` eipr #
�^ TOTAL:
BUILDING HE
FEE SF,ISMIC FEE
ELECTRIC FEE
HOUSING MITLGATIO BE
PAID
Date Receipt#
'• TOTAL: -
gvISSUANCE DATE
ISSUE D BY: