S 1108F
zz
4
z
F
fYi
ILd
d
aU.
U
V.,
U
FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
......�... BUILDING - E.LF.CTR
BUILDING DIVISION APPLICATIONIPERMIT
0
4
PERMIT INFO
CI /1)fll �I�II I ❑ Consultant Fees Paid by Applicant (initial) I BLDG FLEC' PLUd
�I VJ ❑ K ❑
I hereby affirm ma I an, licensed under provisions of Chapter 9 (commencing _
wish Section ]INNO of Division J ofthe Business and Professions Gyle, and my license is
in fall farce and off e t. t� �Q
Licence Class 3 a Lla.If 5
Dan,— Convenor
ARCHITECTS D TION
I Understand my plans shell be at us ub' a ads
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby aff nd that I am exempt from the Con mcum's LicenI
the
following reason. (Section 7031.5, Business and Professions Code: An
which requires a permit to construct, alter, improve. demolish. or repa
prim m It issuance, also require. the applicant Caroni permino file a s
Na he is beemaripturvicartan disprockimesufthe Conweme, License U.(Confetti
Icnmmencing with Scene. 70000) of Dives on 3 of the Business and Professions Cale) Or
that he is exempt therefrom and the basis for the alleged exemplion. Any violation nl
Section 7031.5 by any applicant for a Formal subjects the applicant to a civil Penalty of
not more than live ho n red dollars S300).
I, as owner of the p rpeny, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7H4. Business
and Professions Code: The Commna's License Law does not npply m an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended Or offered fo�rw .n.e
sale. If, however, the building or improvement is sold within one year of cdIAa.Qtp]
comarbuilder will have Nlow
den to en of pmving that he did not build m imp vat) par -t }.
pose of sale.).
x
❑ T. as owner of the property, aexclusively contracting with licensed c vec
m tors to
construct the project (Sec. 7044. Business and Professions Code:)The Co sees Li.
ease Use does not apply man owner of property who builds or improves then m, and QTY.
who contracts for such projects with acontmcmds) licensed pursuant o the Contractors
License Law.
I am exempt under Sat. . B is P C for this reason
Owner
Dom
ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES — RESIDENTIAL.
PANELS
UPTO200AMPS
OVER 10000 AMPS
SIGNS ELECT RICAL
SPECIAL CIRCUIT'/MISC. A1LCA�
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOI, ELECTRIC
OUTLETS —SWITCHES— FIXTURES
NEWRFAJDENTIAL ELECIR SQ IT..
1 hereby affirm under penally of perjury ane of the fallowing declamumne:
Tum"will maintain a Certifcam of Consent m self -insure for Workers Compen-
provided for by Section 37W of the Labor Cade, for the performance of the
which this panni, is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
) of the Lubar Code, for the performance of the work for which this permit is issued
My els C. noun ounce ca d Policy lyrgrbgP�rs�o
Caron 11 iq.-� Policy No.: IL�Ml'+L
CERTIFICATE OF EXE POON FROM WORKERS'
COMPENSATION INSURANCE
(This section new not completed ifthe permit is forms, hundred dollars (g100)
ml s)
(certify that in the any
of the work for which Nmi
is pertisissued. Ishell
not employ any penton in any mannerr so as to become subject to the Workers' Compat-
sation Laws of California. Date
Applierma r
NOTICE TO APPLICANT,If. after making Nis Cimificme of Exemption, you should
become suhjcct to the Worker's Compensation provisions of the LaNa Cede, you must
forthwith comply with such provisions or this permit shall be doomed revokW.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is v convection lending agency for the performance of
,he work for which this permit is issued (Sec. 300. Ci, C.)
Tondces Name
Lender's Address
1 certify that 1 have read this application and stem that the above )nfonnatlon its
correct. I agree to comply with all city and county ordinances and two laws relating to QTY.
building consvuction, and hereby admitted repremomtives militia city to enter upon the
abnve.memioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless me City of Consomme, against
liabilities, Edmas and expert. ,which inuy in any way vccmc vgaina Haid City
nmsryugmmnomi ani,APPLILL COMPLY WITH AL NON- INT
OU
SPpITM n pplit.wContmcmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupant Imre or handle h:¢a bras material
as defned by the Cupertino Municipal Code. Chapter 9.12, and me Health and Safety
Crile, Section 25532(04!
❑Yrs ON.
Will the upplican, or future building occapant use equipment or devices which
Joos air connotations as defined by the Bay Area Air Quality Management
"s ONO
1 have read the [vicarious materials requirements under Chapter 6.95 of the Cali-
I
Health & Safety Code, Sections 25505, 25533 and nSJ4.1 undersand What if the
ng does not currently have a tenant, that it is my responsibility m notify the Oecupam
r.-ryirements which must he met prim to issuance of s Certificate of Occupancyr or t u lamed agent Date
E
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER — DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE.
DRAINS—FLOOR. ROOF, AR ,COND.
FIXTURES — PER TRAP
GAS — EA. SYSTEM -1 INC. 4 OUTLETS
GAS — F.A. SYSTEMi 4 DA)
C.RRASFANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER — SANITARY — STORM EA. 200 FT.
WATER HEATER WNENI'/CLECDd
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT' ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT CIO 10.0000 CPM)
AIR HANDLING UNIT (GVHR 10,000 CFM)
EXI IAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,00) BTU)
BEATING UNIT (OVER I WOOD RTU)
VENTILATION FAN (SING LL RES ID)
MOILER — COMP (311P OR I INTNXT BTU)
BOILER—COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDLM'IAL MECH. SQ. FT.
FEE
FEE
FEE
JOB DESCRIPTION
TDWL
C KITCHEN REMODEL
ADDITION
C PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
CCHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
CBATHRr ODEURF.PAIR
❑DLMI0O1 TION
fiR
lA. CL M
CA
a �1c31Tt-lc �
COMMERCIAL
❑NEWBLDG/ADDITION
❑DEMOLITION
C TENANT
CFOOD SERVICE
IMPROVEMENT
C OTHER
SQ. FT. FLOOR AREA
P A l o
MAY Is An
� U. Ill ,..—., t
PAr
ILDING DIVISION EELS
PLANCHEC
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt a
TOTAL:
BUILDING FEF.
SEISMIC FEE
PLUMBING FEE v V
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt x
TOTAL:
BY: