99080207APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION
APPLICATION/PERMIT
PHONE:
I.IC NO:
PHONE:
1 hereby alfirm that I am licensed under provisions of Chapter 9 ((commencing
�pZ with Section 7WX))of Dirision 3 ufthe Businessland Professions Code. and my licenseis
C) moll finee and eau ([D v�G
a _ u Licca Clan. O Lica !�
hasDa(e��--`� Contractors .P)50>1
1R HITECI"SDECLARATION
Z ~ON L 1 understand my plans shell be used as public records
OZ`"C
F L F W Licensed Professional
BUILDING PROJECT IDEN'YTFICATION
G �"
ON IRACI'OR'S NAME. LI O:
-�T ,,4<'�/J P d' d
.IIIIRLS,S', TZ / S" 6/ ce.
❑ Consultant Fees Paid by Applicant (Initial)
TTY ELECTRIC PERMIT FEE
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2 W AMPS
OWNER BUILDER DECLARATION
C w Q I hereby d irm that 1 .,it exempt from the Contractor's License Law for the
3a-
a -F ry.
following reason, (Section 7031.5, Business and Professors Code: Any city or count
y which requires u permit fiim
t conduct, alter, prove, demolish, or repair any structure
F atn 4 prior fit it issuance, also requires he applicant for such permit to file a signed saftement
�y)Y� that he is licensed puruantto the procivionsof the Contractor's 1, cense Law (Chnpmr9
(commencing wire Seen..7IIq)of Division 3 of he Business and Professions Code) or
61 that heisexempt therefrom and the basis for the alleged exmnptlon. Any violation of
W m_ li Section 0031.5 by any applicant ler a permit subjects the att,hronl w u c'tvll penalty or
F Znot more than Eve hundred dollars (55006
ESQ❑ Lasownerofthepntpertyar ... enrglnycu with wages rsa weir axle unngensulina
p.. will do the work. and the aructum is not intended or offered forsele(See9lw. Business
L3 m and Professions Code: The Contractor's License Law does not apply to an owner of
pv,Nrty who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
wle.If. blowout, he buildingor innpttrvoneem—old vellum enc yearufenmplctian, the
crTailder, will have the burden of proving that he did not Wild or improve for par-
, Nom nLwled.
OL as owner of the progeny, tun exclusively contracting with licensed contractors to
constructmode
e projeet (Sec. 7014. Business and Professions C:) The Contractor's L
ni-
n eLaw docs nor aEgly to frowner if popenywho bvilda or in ...... os, thereogand QTY.
whit contracts for such projects with a contracmr(a) licensed amatual to me Control
License Law.
❑ I am eacmpt under Sce. . I & P C for this reason
Color Don
WORKER'S COMPENSA'DON DECLARATION
1 hereby affirm under penalty of perjury one of he following doelamtions.
1 have and will maintain a Ceai ficata of Consent nn selfaroare for Workers Comlgn-
provided for by Section 37W or the labor Coalfor the performance of the
n k as for which this permit is issa, d
IZ have and will maintain Workers Compensation Insurance, as required by Section
oyne ladow Cute, for the performance of the work for which this perion,is moo,
y Wnderspguasyl�n lnNyynewrrjq and Policy numbcra
Carrier C.�LL-/' f JNolicy N.
K
,EIITI�(,Ofi�lv�PPION Pk(1M W(tkKEH$"�J/W
COMPENSATION INSURANCE i
(This section need not W completed if the canit is for one headed dollars ($lip)
or loss.)
1 cerify the in the perfom Bare, of the work for which his permit is issued, l shall
amt employ arty wr oul ill arty manner an as It, become subject m the Worker' Cnril
Z station Laws of Colborn.. Dae
zo Applicant
y
NO] 'ICE '10 APPLICAN'P.. If, .tier making this Cemilicate of Exemption, you should
a>
become subject to the Waders Compensation provisions of the LeWr Cole, you into,
forthwith uarnply old, ech Pra
v
e as.ns ,, his grnoo, hall be declare re,oked.
Q
7 CONSTRUCTION LENDING AGENCY
Ub I hereby affirm that there is a concoction lending agency for pdromfnce of
D. H he work for which his permit is issued (Sec. 3097, Civ, C.)
Q U lander'. Nunac
Lenders Address
1 certify that 1 have rod this application and sole, that the annve information is
'r U) correct. l agree to comply with all city and county ordinances and state laws relating to QTY.
U IZ budding construction, and hereby authorize representatives of his city to enter upon the
abovcmc do ned prnlwily Iter iaspcctimn pm,oses.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Nobilities, judgmenaa, core and fxpenses which mey m any way.seme again., said City
in consequence of the granting of this perinh.
APPLICAN'ANDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will rhe applicant or future building accumant store or handle harzrdoes material
as defined by the Cupermno Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(x)?
El Yes >611
Will the applicant or fnauc building occupant use equ,nionl or devices which
t harroom s air contaminant as defined by the Bay Area Air Quality Management
ricl?
F] Yes Ed No
I have read Ino ha,urdoes nmeerads requitement under Chapter 6.95 at me Cali
forma Health & Safety Code Sections 25505,'_5533 and 25534. 1 undersmnd that Raw
building`soul cuncntly huvcry mnunt.mwit is my rc......
argent,
nillty lm notify the rmrupunt
yfjlne fegdtmems which at.,, be noel once Of a Cur to Occupancy.
ilii_ if%/." -n- vc
SIGNS ELECIRICN,
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL 17LECTRIC 10
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK ROW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, POND.
FIX T TRES - PER 'I'RAP
GAS - EA. SYSTEM -1 INC, 4 OUTLETS
GAS - ISA. SYSTEM OVER 4 (EA)
GREASEIINDUSTRL WAS'T'E INIERCT:YIOR
GREASE I'RAI'
SEWER - SANITARY - STORM EA. 200 FII
WATER HEATER WNENT/ELECI32
WATER SYS H2M.G RFATING
K'A'1'12R SERVICE
NEW RESIDEN TIAL PLMB. SQ. PI'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD FO MECIL
AIR HANDLING UNIT (TO 10,0011 CFM(
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (W/DUCT)
EpA'rdoG UNIT (TO 100,000 BTU)
HHATING UNIT OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP CHIP OR 100.001 BTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, FT.
TOTAL:
OFFICE
FEE
NIC
RFS 1IDFS_RENiNTIAI;
CONTRULp
❑ Stiff
❑ KITCHEN REMODEL,
❑ADDIT[ON
❑ PLUMBING RE-PII'E
❑MULTI -UNIT
_BUILDING
PERMIT INFO
MOD ' ATION
BLDG
ELECT PLUMB
MF.CH
E]SWIMMING POOLS
p ❑ ❑
❑
JOB DESCRIPTION
RFS 1IDFS_RENiNTIAI;
❑ Stiff
❑ KITCHEN REMODEL,
❑ADDIT[ON
❑ PLUMBING RE-PII'E
❑MULTI -UNIT
El STRUCTURAL
MOD ' ATION
❑ INTERIOR
IMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑ BATH REMODEUREPAM ❑ DEMOLITION
❑ OTHER
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
dFE,NANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
n
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING IEE
SOILS FTSE
FEE
MECHANICAL FFE
CONSTRUCTION T
HOUSINGMITIGATIONtE
PAID
Dat, Receipt#
ISSUANCE DATE
f-3 a -FP