The URL can be used to link to this page

S 1092F tY a APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OFCUPERTINO BUILDING.. ELRCrRICAL CAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING CTIDENNIFIC 1/�� I�f 1f/ BUILDING PROJECT IDBN'1'It'ICATION BU/JO IA ri ISS: £ ix f W e_ S " • C' i wj�..�(-%� n -O CA 950 �- OWNFR'S NA7MP r /}��JI PHONE: f] CONTRACT'OR'S NAME: / A x J.ICbV4 ❑ Consultant Fees Paid by Applicant (Initial) 1 hereby utfinn that 1 am licensed under prnvisinns of Chapter 9 (conata7ming with Satlnn 7118)((��ARRtt'IT''D11ffl��ivmff,//io�nn3''``3��of be Basins, and ' A]ji'rionslI Code, aaid Ina Iiov,,c Is in liJl fords nAc 'milo llp O� Liccnw Clan Dmc ConDEC ARCHITECTS DECLARATION eOWNER-BUILDER DECLARATION I hereby .'sin that I oto exempt from the Contractor's License Low for the fullnwing reason. (Section 7031.5. Business and Professions Code: Any city ar county which term., a permit m cunstroa. alter, improve, demolish, or repair any su ratio, prior to its issuance, also require%the applicant for such Permit o file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division of the Business and Profecsio® Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of not more than rive hundred Jolles ($500C ❑ L its owner of the property. or my employees with wages as their sole Cvntpeneatimv, will Jo the work, and the structure is not intended or offered for sale (Sae. 7014.I5usiness and Pod ..inn% Crcic: The Comment, Lucerne Law Jens nut apply e, vn( properly who build%# mn proes thereon, and who Joe %ueh work bur self nrthrough his own employees, provided that such imp cvrmcnu am not intended or offered for .rale. If, however. the building (it improvement is sold within one year ol'eontplenon, the sw mbudderwillhavetheburdenofprovingthathedidnotbuildorimproveforpar- qne of sale.). C] 1, as owner of the property, am exclusively contracting with licensed contmmon In instruct the project (Sec. 7014. Business and Professions Code:) The Cnntrumors Li- ceme Law fres not apply to an owner of property who builds or improves thereon, and QTY who curl far such pmjeas with a cnntraaod,) licensed trarsaanun the Commence, Liceme Law. ❑ l am exempt under Sas .B& P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the fallowing deClemnions: ❑ 1 have and will maintain a Certificate ofConxenuo self -insure for Workers Compen- sation, as pmvideJ far by Section 3700 of the L,o or Code, for the (srparri.me of the wy k lin which this pcmnh is icvucd. {4 I have La will odintain Worker Compensation rkfor which h his pert by Neches. /{1(111 of the Labor ('uJe, for the perfonnanccof the work for whieM1 this pcmlit Is ism eq. COMPENSATION INSURANCE fliis %action need not M completed ifthe permit ix f rune M1unJred Jnllam (EHN) orless I I cenily thin in the performance of the work far which this permit is issued.) shall not employ any person in any manner so as a+become subject to the Workers Compen- 0 satlon Laws of California. hate Z 2 Applicant N NOTICE TO APPLICANT: If, after making this Cer ific a if Exemption, you %M1auld a ; become subject to the WorkersCnmpensaion pear, Wonn of the Latin Cede, you mint forthwith comply with such provisions or this permit hall be deemed resoled. Uz CONSTRUCTION LENDING AGENCY U 1 I hereby his that there issco (Sen. 30 lending7,C. agency for the performance of � F-' the wmkfar which this permit is issued (Sec. 309], Civ. CJ 0 U lender's Name lender's Address I cenily that 1 have read this application and nuts that the above momnAon is V) correct. I agree to comply with all city and county ordinances and state laws relating to QTY. UZ holding con,lomilon. and hereby atdmrim opre,emotivesolthis city R+ enter upon the abovo-neationed property for inspection purposes. (WW ogres #+ save, indemnify and keep harmless the City nI'Cnpeninn against linbilitics,judg of (hecoots and expenses which may in any way accrues against salA City in nICANIce NDE STAN S this permit. SOURCE RE UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. Signature o(Applicanl/Conlrecmr Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle Woodau% material as defined by the Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety Cal, Section 25532(x)" ❑Yes L] No Will the applicant or future building occupant use uquipment or devices which ^mit htimb un air contaminants as defined by the Bay Area Air Qual'ny Management District? ❑ Yes ❑ No 1 have read the hanolous materials requirements under Chapter 6.95 or the Cali- fomin Dealt & Safety Code, Section, 2550.5, 25533 and 25534. 1 undemland that if the hoildine docs not aunicn 1, have n tenant. that i+ o my rcxnonriblllry m n++flb 14 r..ai++um ELECTRIC PERM I PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANELS UP TO 200 AMPS 201-1000AMPS OVER U100 AMPS SIGNS ELECTRICAL SPECIAL. CIRCUITIMISC. TEMP. METER OR POLE INS'('. POWER DEVICES SWIMMING POOL ELECIRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELEC'I'R PLUMBING PERMIT PERMIT ISSUANCE ALTER - DRAIN & VENT- WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS - FLOOR. ROOF, AREA, CONI(. FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC, 4 OU'I'LETS GAS - EA. SYSTEM .OVER 4 (17A) GREASUINDUSTRI, WASTE ISIT ERCEP TOR GREASETRAP SEWER - SAN] TARY-S'I ORM HA. 2011 T. WATER HEATER WIVEN'I'/Ii1.EC1'R WATER SYSTEMO REATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. En MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECIL AIR HANDLING UNIT (q() umox) CEM) AIR HANDLING UNIT (OVER MAX) CFM) EXHAUST HOOD OW/DUCT) HEATING UNIT (TO 110.010 B'IU) HEATING UNIT (OVER 10.0Ml BTU) VENTILATION FAN (SINGLE RLSID) BOILER -COMP (THP OR 100.0 o BTU) BOILER - COMP (OVFR 100,00 t 1O U) AIR CONDITIONER NEW RESIDENI]AL MECH. SQ, Irl'. 2.a Cl/ A"1 SQ. PI'. FLOOR AREA FEE I P A I CITY Ur Uurcn i INO STORIES BUILDING DIVISION FEES PLANCHECK ITE ENERGY PER GRADING PGE SOLI S FEE PAID Date Receipt# TOTAL: BUILDING FEE FEE SEISMIC FEE ELFC9'RIC ITT! PLUMBING FEE MECHANICAL ITE CONSTRUCTION' TAX HOUSING MITIGATION ISSUANCE DATE S/SQ. F NIC ❑ CONTROLM BUILDING PERMIT INFO BLI3C I.I.Ecl PLUMB NIECH ❑ ❑ ❑ 'L�C`�Jr EEE JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION 1-1 PLUMBING RE --PIPE ❑MULTFUNI'T El STRUCTURAL MODIFICATION ❑INTERIOR El CHIMNEY REPAIR IMPROVEMENT ❑SWIMMING POOLS ❑ BATH REMODELCREPAIR ❑ DEMOLITION ❑ OTHER COMMERCIAL: []NEW BLDG/ADDITION ❑DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ TITER SQ. PI'. FLOOR AREA FEE I P A I CITY Ur Uurcn i INO STORIES BUILDING DIVISION FEES PLANCHECK ITE ENERGY PER GRADING PGE SOLI S FEE PAID Date Receipt# TOTAL: BUILDING FEE FEE SEISMIC FEE ELFC9'RIC ITT! PLUMBING FEE MECHANICAL ITE CONSTRUCTION' TAX HOUSING MITIGATION ISSUANCE DATE S/SQ. F