30684APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
CITY OF CUPERTINO BUILDING -I
BUILDING DIVISION APPLICATIONMERMIT PLUMBING -1
BUILDING PROJE(
I LDING ADDRESS:
$6b BETTE ANG GUDE'R_'CNJO, eA Accu
18011"
PEKMtt Nu, 3 0 6 8 4
NITARY NO. APPLICATION SUBMITTAL DATE
1211CL6
N/C CONTROL#
❑ Consultant Fees Paid by Applicant (Initial) BLDG
I hereby affair that 1 am licensed under provisions of Chapter 9 (commencing
CZp with Scalion]J00)ofDlvfsmn3uftbe Business and Prof ..mrs Code, and my l imnse is
in full farce add effect.
UU License Class Lic. 4
F Y1 Dat< Cmdoormr
F D on ARCHITECT'S DECLARATION
OO y] 74. I understand my plans shat l be used as public mamas,4 •�.i Liven J Pn fessinnel
go�OWNER-BUILDER DECLARATION
yy I hereby affirm that 1 an exempt from the Con manta's License Law for the
1 an a empt from the Con manta's Lic nse Law for the
pd 0 d C] following res son. (Section 7031.5, Business and Pmfes ions Code: Any city or ounty
RR17 V. which requires a permit to construct, alter, improve, demolish, or repair any summit,
L� prior to its issuance, also then applicant for such permit m file a signed statement
requires pp pe g
� ¢ that he
mendenlicesedwith
pSectioon 7 the provisions of their Bminess License Loons Code) or
,l�j
(commencing it therefrom add
dth Division of theeged exemption and Professions Code) or
d c I that he is exempt therefrom and the basis For the allege) exemption to Any violation of
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
F Z Y not more than five hundred dollars (ESgD:
d C L. owned, the prnputy, or my employme with wages os their sale compensation,
a will do the work, and thesucmrc is notimended or offered fnreale (Sec. ]014, Business
and Professions Code, The Conductors License Law does not apply to an owner of
pmpeny who builds m improves re
theon, and who does such work himself or through
his own employees, provided that such Improvements aro not intended or offered for
sale If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for par,
,.,eof sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct he project (Sec. 9044, Business and Professions Code:) The Commences U-'
ase Law o not ap ay to an owner of propeny who builds or improves thereon, and QTY,
who contua efnrh jecUwithecontmcmr(s)licensed pursuammthe Cantroctors
License Law
Clam oxen to ,R&PC tit thilroccur
r Dae
WORK 'S COAyi SA'DON DECLARATION
I hereby affirm under amity of pe jury ane of the following dedamtions:
I have and will maintain a Certificate of Consent to self -inure for Worker's Compen-
as provided for by Scares 3700 of the Labor Cale, for the performance of the
ark for which this permit is issued '
1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Crde, for the performance of the work for which this permit is issued.
My Wmkcr's Compensation Insurance carrier and Policy number arc:
Cartier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is fosse hundred dollars ($1 W)
s or less.)
I certify that in the Performance of the work for which this permit is issued, l shall
not employ any Person in any manner se as to become subject to the Workers' Compou-
0 Z cation Laws of California. Date
Applicant
ib FN -t NOTICE TO APPLICANT Ir, after making this Certificate of Exemption, on should
F' I histoma subject to the Workers Compensation provisions of the Labor Code, you most
'forthwith comply with such provisions or this permit shall be deemed revoked.
Q
ZCONSTRUCTION LENDING AGENCY
L1 Q Ih<rehy affirm thanhere isaconsuaion lending agency for the performance of
LL f~'I work for which this permit is issued (See 3097, Clh, C.)
Q LenJa'a Name
Lender's Address
I certify that 1 freeness] this application and state that the above information is
H V1 correct. l agree m comply with all city and county ordinances and state laws refuting m QTY.
V 4 building construction, and herebyauthmlze representatives ofthis city to enter upon the
above-mentioned propeny for fnsp,mfnn prujI
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liahilities,judgments, costs and expenses which may ready way accue against said City
in consequence M the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature ofApplican ,Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardons material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)? -
❑Yes E] No '
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management
strict?
❑Yes ( E] No
I have mat the hazardous materials fidgma oro under Chapter 6.95 of the Cali.
forma Health Se Safety Cork, Sections 25505533 and 25534, 1 understand Oat if the
building does not currently have a tenon. IF it is my responsibility to notify the accupant
of the requirements which must be met prioa issuance of a Contrrom of Occupancy.
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL , G
SPECIAL CIRCUIT/7,115C.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
JOB DESCRIPTION
RESIDENTIAL:
C SCOWL
C KITCHEN REMODEL
CADDITION
El PLUMBING RE -PIPE
❑MULTI -UNIT
11STRUCTURAL
ALI DRAIN VENT (EA)
MODIFICATION
C INTERIOR
C CHIMNEY REPAIR
IMPROVEMENT
.'
!ATH REMODEL'REPAIR C DEMOLITION
OTHER
DEC. GROUP
COMMERCIAL
El NEW BLDG/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
NEW RESIDENTIAL ELECTR SQ FT.
SQ, FT. FLOOR AREA
P A , {1
lJ
/*L4Iu ��aq
lI
TOTAL:
PLUMBING PERMIT FEE16
PERMIT ISSUANCE
ALI DRAIN VENT (EA)
�f-ChV N
DEVWATICE
BACK FLOW PROTECT. DEVICE i
BACK FLOW TECT.D
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE C(
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
DEC. GROUP
GAS - EA. SYSTEM -OVER 4 (Eat)
GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 20) FT.
ENERGY FEE
WATER HEATER WNENT/F.LECfR
GRADING FEE
WATER SYSTEMITREATING
SOILS PEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FE
Data Receipt# ,
TOTAL:
TOTAL:
BUILDING FEE
IO
MECHANICAL PERMIT FEE
SEISMIC FP.E
PERMIT ISSUANCE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO Iff" CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
CONSTRUCTION TAX
EXHAUST HOOD (WMUCT) HOUSING MITIGATION FEE
HEATING UNIT (TO Kilt 10 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID) PAID
Date Receipt#
BOILER -COMP EHP OR IOQ(W BTU)
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER - ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. IT.
OFFICE
VSQ. FT.
POST THIS CARD NEAR FRONT OF BUILDING
CUP INO r
BI>l>(DR7G DryLSIS1ON
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INSPECTION RECORD
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FOUNDATION/PBi LcAw.S. .- ..,:
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NOTE: ALL 'GRADING `AND DRAINAGE
gFs@P2IDA{: `.' _
❑AWL `_.-:_
' UFER GROUND
SHALL BE INSTALLED TO COMPLY WITH
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PAD/SEI•BACK-CERT --
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THE APPROVED 'PLANS 'AND CITY OF
CUPERTINO STANDARDS.
❑tYDllli•UNII' CISMUCnMAL
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GARAGE SLABSIPREGUNI E
GE INSPECTION
❑SWAM
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ONS (12:30 PM - 4:00 PM)
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UNDERGROUNDISLAB
CALL AF•TE
771-3228MON YTO FRIDAY 24 HOURS BE-
❑onme
PLUMBING
FOREINSPECTION. JOB ADDRESS
.QWIREDELEC-MCAL # ARE NEEDED WHEN PHONING.
combumcIAL
•
~~
ATTENTION CONTRACTORS:
❑NGpBLMADDITION OIC
RVICS
PLUMBING
NO PERSON(S) SHALL PERFORM WORK ON
iu6+A�oxZ/�+F .
-.
THIS JOB SITE WITHOUT BEING IN COM-
py
.
.MECHANICAL -
WITH WORKERS' COMPENSATION
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PLIANCE
INSURANCE REQUQtEMENTS'•
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FRAMING VINCS -:<< .•y3nT..'r.' ..
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INSF
REQUIRED p❑
INSULATION
INSPEMON SPECIAL INSPECTION
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CERTIFICATE
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READ REVERSE SIDE'BEFORE
PLEASE
CALLING FOR FINAL INSPECTION!!
i5511ED BY: