99120006APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1CITY ;OFCUPERTINO BUILDING
LU
BUILDING DIVISION APPIACATION/PERMIT -suefs'G-MtiouAl
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rreavtu ry
I OFFICE
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OWN NAM i: I 4. PHONE:
CO�'fRACi'O:.7ME, f LIC NO:
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CHITEIT/F,NGI HER LIC NO:
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CONTACT PHONE:
BUILDING PERMIT INFO
B}L�DJf ELECT PLUMB MUCH
V? ❑ ❑ ❑
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1Y C/.�r\
❑ Consultant Fees Paid by Applicant (Initial)
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LICPNSUD CO TRACTOR'S DECLARATION
I hereby alarm that I am licensed unser provisions of Chapmr 9 (commencing
with Safion]000 ,inn 3tsfthe Business and Pnd'ess]ots Cole, and my license ix
in lull force erns Te v
Licenw Class LICK
)am Cnntmcm,
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL;
❑SFDWL ❑KITCHF,N RF.MODEI.
❑ADUII'ION El PLUMBING RE -PIPE
❑MULTI-UNnr ❑STRUCTURAL
MODIFICATION
[-I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
BATH REMODEUREPAIR ❑DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENT IAL.
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06 Ufdlawmgreason.
CO
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)F.CLARATION
Iwokostan paasshallheusedas ublierecords
Licensed P asenal
OWNER -BUILDER DECLARATION
I hereby aMnn that I am exempt from the Clause ors License law for the
(Section ]831.5. Businessand Profe ions Cade: Any cityor county
which rtquires a permit to comiruct, Ban, improve, demlish, or repair any wasameprior to its issuance, also requios me applicant finwch Formula file a signed statement
he is licensed Earommnvhe provisions ofde Commands License Lave(Chapter9W
(commencing with Section 9000 ofDivision3ofthe Business and ProfessionsCode)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
703 lS by any applicant fora Ended, subjecre the applicant to a civil penalty of
10 AMPS
MPS
)AMPS❑
nIANC
ECTRICAL.an
IRCUITIMISC.that
TER ORP ST.AMM
R .lAl:aL�!,
❑^ N�EW BL ION ❑ DEMOLITION
CTl.rv/Srv1 ❑ FOOD SERVICE
EVICE
mSection
F Z_i•
=0
L.O
not mom then five hundred ddlas(E580).
�1, an owner of the progeny. or my employees with wages as their sole compensmion,
will do the work,mul theslmewre is not intended mothered for sale (See. 9(144, Business
wJ Professions Cade: The Contmcmr's License Law Sent not apply to an owner of
IMPROVEMENT
❑OTHER
SWIMMING POOL ELEC C
OUTLETS-SWI4TR"
NEW RESIDENTIAL
5C
�' ..
property who builds or improves thereon, and who does such work himself or through
his own employes, provided tbat such improvements art no man tkJ or offereJ for
sale. IL howeverJhc building orimprovemem is anlJ within oneyearof rnmplednn,he
owner -Wilder will have the burden of proving that he did not (wild or improve far pur-
SQ. PI'. FLOOR AREA
USQ. Ff.
T AI:
poscasaleJ.
I, us owner of ct progeny, . B edus and rontessions, with Ii The Con ntmnors i-
Li -
cause La the Project (Sec. ]two, Business and Professions ds or i The Gwuomon. anti
aofpmpcny who
cause Lawdtscsndapply toan withsedporlmprove Comment's
who contracts for such projects with a convucmr(s) licensed pursuant m Ne Comracmr's
QTY, PLUMBING FEE
License Law.
❑ I am exempt under See ,B& P C for this reason
PERMIT ISSUAN
ALTER- DRAIN TROTA)
VALUATION
Data
WORKER'S COMPENSATION DECLARATION
BACK PLOW PR
I hereby affirm under Penalty of perjury one of the following declarmions:
❑Ihvvc and will maintain aCTnifcate of Consent to selGineurefor Wndkers Compen-
DRAINS - FLOO
STORIES TYI'ECONSTRI1CT101
section, as provided far by Section 37M of the labor Code, for the perftxmunen of the
work for whi<M1 this Eamon is issued.
FIXTURPS -PEN
GAS -EA.SYSTfiM-I INCA OU'I LE
1 hove and will maintain Worker's Compensation Insurance, as required by Section
3101ofthc Lutxa Cada for the pertormance of the work far which this Ecnnit is issued.
OCC. GROUP ils
!O
CAS -EA SYS'T13M-OVER4EPA)
My Workers Compensation Insurance carrier and Policy number are:
Courier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
J
GREASFANDUSTRL WASTE INI'ERCEPI'OR
BUILDING DIVISION FEES
GREASE TRA
SEWER - SA
PLANCHECK FEE
z
zApplicant
fA
(Thi,satimmialnnt be comElereA iDhe pcmtit is formchundmd dnllvn(51001
or less.)
I certify that in the performance ofthe work forwhich this permit its issued, l shall
not employ any Psubject Person in any manner so as to become subjeco the Workers' ComPen-
satlon Laws of Califomia. Data
I
ENERGY FEE
WAFER HEMjSMffM
WATER SYST
Mff
ftft'
Eff
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
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become subject to the Workers Compensation provisions of the Labor Code, you most
faMwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency far the performance of
the work for which this Two it is issued (Sec. 309], Civ. C.)
WATER SERV
NEW RESIDE IT.
QTY. MECHANICAL PERMIT •1•E
((JJ''rtrt N^nQ
�! Vf
Date Raeiln#
TOTAL:
Lenders Name
Lcraftl Address
1 t, fy,hat I have mad,his "hemian and 'W ,'bat the ahnve information is
ntrrat.I agreem comply withal]city and county ordinances and stake laws relating m
huilding conswmion. unJ hereby nwhoriu rcpmsema,ives of this city fp emerupm the
ILDING FEE
SEISMIC FEE
abovomrmioned pmpeny for inspection purEoses.
(We) agree to sour, indemnify and keep hannkss the City of Cupertino against
liabilities, juagmenta. costs and expenses which may in any way accrue againnsvid City
in omegmence f,he gmming of this permit.
APPLICANT UNDERSTAN 4 ILL COMPLY WITH ALL NON -POINT
PERMIT ISM
ELECTRIC FEE
PLUMBING IEE
ALTER OR AM TO MECH.
AIRHANDL
SOURCE RFGI H ATLWZ5:
I1/` ISS
AIR HAND UM (OVER 10.000 OWE
CONSTRUCTION TAX
I
Signawrcof APPh", i'ommcmr TDatc
HAZARDOUS MATERIALS DISCLOSURE
Withhc ai,beantor future bulldingaccupan,,Iona, handle harardon, material
as defined by the Cnpenino Municipal Code, Chapter 9. 12. and the Health and Safety
Code, Sethon 25532(a)1 ❑Yes
C�
g
EXHAUST H70(75 77D.,
blFUIi
HEATING UNIT (TO 100.0000 BTU)
HEAT) NO UNIT (OVER 1011,000 BTU)
PAID
Date Receipt p
VENTILATION I-AN(SINGLE RESID)
Will the applicant or future Wilding ..pal use equipment or devices which
mit Imitate., air connotation, as defined by the Bay Area Air Quality Monagemeal
BOILER - COMP GRIP OR 100,000 B'HD
TOTAL:
District?
❑Yes
BOILER- COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE
I lave red the Wordius matmids tequiremems under Chapter 6.95 of the Cali-
NEW RESIDIiNT1A1. MECH. SQ. FE
ftnnia IIeIN & Safe, Cwl,, Section. 3 and 25534. 1 understand that if the
indoes not carona teranLthmitnity pansibilitymnIatifythccecipant
of the seouiwmenu t nnor m iourm, of a Cef i(eny mf 10ytifaney.
/
I OFFICE