9909008FAPPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY AD
CITY OF CUPERTINO BUILDING ELECTRICAL P MIT
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGS 11 SANITARY NO I APPLICATION SUBMITTAL DATE
00INI -Ttslg
wwI of
❑ Consultant Fees Paid by Applicant (Initial)
LIC41,SE13CUN'IRA I URS UECLARA I LUN
I hereby afford that 1 am IicensW undtt provisions of Chaplet 9lcommencing QTYELECTRIC PERMIT
with Secllon7"),I'Divi,mr3oflhe Businessand Pndessiomcade. monat"bireacis + LPANELS
ISSUANCE
in full force and effect. 7 ( I V11
License❑ a Lic.p
Da¢ Contracmr —�� CES - RFSIDF.NTIAL
ARCHITECT'S DECLARATION I understand my plans shall be used as public records -1
OWNER -BUILDER DECLARATION
RESIDENTIAL
C SFDWL.
I hereby affirm that 1 am exempt from the Catharines License Law for The
❑ADDITION
following reason. (Section 7031.5. Business and Professions Cale: Any city or county
❑MULTI -UNIT
which requires a permit to construct, Ater, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant fur such Permit o rile a signed statement
C INTERIOR
,has he is licensed pursuant to the provisions of the Commoner, License law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
AROJEMENT
BREMODEUREPAIR ❑DEMOLITION
Mat he is exempt B erefmm and The basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant far a Permit auhject, the applicant m a civil penally of
not mom man five hundred dollars (4500).
C I, as owner of me progeny, or my employees with wages as their sole compensation,
will do The .,it, and the structure is not imendel or offered hassle (Sao 7044, Business
and professions Code: The Compactors License Law does riot apply In an owner of
1
Property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvement,, am not intended in offered for
side. IL henvevee he building or improvement is snW within one year of completion, the
m wrier -builder will have The burden of proving that he did not build or improve for put.
poseof salat
1. as owner of The property, am exclusively contracting with licensed contractors to
curovon The pmjeel (Sec. 7044, Business and professions Cade:) The Comments" Li-
cense Law does not apply or an owner of property who builds or improves theater, and
QTg
who contracts for such projects with a coat crams) licensed pumoant to the Connacmrs
License Law
C lam exempt under Sec. ,B&P C for this..at
IF
owner Date
WORKER'S COMPENSATION DECLARATION
s I hereby affirm under penalty ofpejuryoneofthefollowingdecla tions:
❑ 1 have and will maintain a Cardinals of Consent to self -m um for Workers Compen-
saload, as provided for by Section 37M of the Labor Code, for the performance of the
work far which this permit is issued.
C 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for mwhich this permit is issued.
My Worker kyr tion Insurance carrier and Policy
Carrier: V : ILy Lel w.J Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm he completed if the permit is for one have raddollms (SIM)
or less.)
1 cenify that in the performance of The work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Workers' Compen-
z sari. Laws of Cut forms. Dam
zApplicant
y NOTICE TO APPLICANT: IL after making this Cert ifcate of Exemption, you should
a ; became subject to the Workers Compensation provisions of the Labor Cole, you must
forthwith comply with such Provisions or this permit shall he deemed revoked.
a
�z CONS'TRUCfIONLENDING AGENCY
U O I hereby affirm that hem is a construction lending agency for the performance of
a. p+ the work for which this permit is issued (Sao 3097, Civ. C.)
Q ULender's Name
Lenders Address
1 I tariff that 1 have read this application and state That the above infommetion is
N correct. l agree m comply with it city and county oriireares and scala laws renting In QTy.
U building construction, and hereby authorix represenmfivex of this city to enter upon the
abnve-mentioned Property for inspection purposes.
(We) agree to save, indemnify and keep hmmless The City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
I. consequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL YON -POINT i
HAZARDOUS MATERIALS DISCLOSURE I
Will the applicant or future building occupant store or handle hazallous material
as defined by the Cupenim, Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(m?
❑Yes
Will the applicant or future building occupant use equipment or devices which
rmii huzardaus air contimmals ea defined by the Bay Area Air Qualify Management
Uisuin❑ /+
Ycs AR
I have read The husardnus materials requlmmeah under Chapter 695 of the Cali.
fomla Heahh & Safety Cade, Stations ^_5505, 25533 and 25534.1 understand thin if the
of In,
domuxne cumen0yb ,. responsibilityeamofymeaernev.
of the rcuuircmtms.aWs Fr cote ogOccmwncv.
TEMP. Mli rliR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
'OUTLETS -S WITCHES - FIXTURES
NEW RESIDENTIAL ELEC R SQ FT.
PLUMBING PERMIT
PERMITISSUANCL'
ALTER -DRAIN&VENT )
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, RCGP, AREA, D. 1
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4 (0A)
GREASOINDUSTR. WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY- STORM EA. 2M FT.
WATER HEATER WNENTIP.LECTR
WATER SYSTEMI'TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTERORADDTOMECH. Az&la.
AIR HANDLING UNIT (TO 10,800 CPM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD (WNUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER Ifsk" BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COME CHP OR 100,00 BTU)
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, IT
OFFICE
TOTAL.:
FEE
MWIM
JOB DESCRIPTION
RESIDENTIAL
C SFDWL.
C KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTI -UNIT
El STRUCTURAL
MODIFICATION
C INTERIOR
❑CHIMNEY REPAIR
❑SWIMMING POOLS
AROJEMENT
BREMODEUREPAIR ❑DEMOLITION
LEG/ADDITION ❑DEMOLITION
ANT ❑ FOOD SERVICE
IMPROVEMENT
D OTHER
SQ. FT. FLOOR AREA /'' VSQ. FT,
Dom t S? 40-
1410, Do -
FEE
VALUATION
'JI SOO I bock
STORIES TYPE CONSTRUCTION
OCC. GROUPl (A AP�
rl
n 3 Jr -
BUILDING DIVISION FEES
PLANCHECK FEE a �.
ENERGY FEE o�
GRADING FEE
SOILS FEE _ ■ry
PAID
Date R ti
BUILDING FEE lYa k
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
Pl-1 fll ri aJi
ISSUANCEDATE
ISSUED BY: �•