31179APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION
APPLICATION/PERMIT
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PHONE:
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end Icy 6q.0itz
❑ Consultant Fees Paid by Applicant (Initial)
C C Z 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
{{yy00 wish Section 7") of Div/is' n 3 of Ne Business and Professions Code, and my license is
a1y� in foil farce wit f6l3& btid3�Jl
<UU Liecnsc class 1O Lic.p
FZN ata -10!1 _� �ARCIUTECf9 tDECLANAI'ION
Z o Qy Z `-1 understand my plans shall be used as public records
OZ —O
[-NnLw I,jgsed Professional
�y S[aj OWNER -BUILDER DECLARATION
L Q I hereby affirm that 1 am exempt from the Cont ationa s License Law far rhe
Sd 3 6 F following reason. (Section 7031.5, Business and Professions Code: Any city or county
F ^O m which requires a permit to construct, alter, improve, demolish. or repair any structure
r !x11 miarto its touuncc,.1... requires theapplicmn for Inch permit d file axigncd statement
999rWW��ps that he is licensed pursuant to me provisions of l he Contractor's Liceree Law (Chapter 9
W (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
0.4 c that he is exempt themfrom and the basis for the alleged exemption. Any violation of
WSection 7031.5 by any aPplicaut for a persubjects the applicant to a civil penalty of
mit not more than five hundred dollars (SSW).
iS G ❑ I, as owner of the property, or my employees wish wages as their role compensation.
p. will do the work, and the swcmre is not intended or offered forsale(51. TW, Business
and Professions Cale: 'D e Contractors License law does not apply to an owner of
property who builds nr improves thereon, and who dues such work hinewif or ihmuph
his own employees, provided that such improvements are not intended or offered for
sale. IL however, the building or improveinean is sod within one yearof completion, the
ter -builder will have the burden of pausing that he did not build or improve for par.
poseofodc.}
I, as owner of the property, am exclusively contracting with licensed contractors to
Dustmen the project (See Il044, Business and Professions Code:) The Contractors Li-
en¢ law does not apply to an owner of pmpeny who builds or improves thereon,and QI'y
who commits for such IF jee¢with a "monitor') Iiconmd pum.u:mna the Commaors
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
sl
10 Date
WORKER'S COMPENSATION DECLARATION
m -
I hereby affirunder penalty of perjury one of the following declarations:
�.hase and will maintain a Cenificme of Consent o self -insure for Worker's Campen-
ution, as provided for by Section 3900 of the Labor Code, for the performance of the
ark for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
7000fshe labor Cale, forte performanccofthe work forwhich this permit is issued,
CrriWcrr rs Qom isalim Isar ce cartie Pool cy Noy gIIN{9[c� 16 a5�t 1
U CERTIFICATE F EXEMPT ION FROM WORKERS'
COMPENSA'DON INSURANCE
(This se Bounced rumbec mpleled ifthepermilisforonehundred Jollury(SIU))
or Icss)
1 candy that in the performance of the work lime which this permit is issued,' Co I shall
n
e ut employ any person in any manner so as to become subject to the Workeers Compen-
� z cation Laws of Culifomia. Dote
Z Applicant
NOTICE TO APPLICANT. If, after making this Cenificale of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Calc, you must
WI fnnhwish comply with such provisions or this permit shall be deemed revoked.
aQ
U Z CONSTRUCTION isaconNLENDINGnG NCY
agency
U., O kforeby wInchthisKuhereissue (See,i01Cingagencyfurthe performance of
(L F the cni for which this permit is issued (Sec. 3097, Civ, CJ
O U 1 imi Name
Lenders Addrescomfy
fir-" y 1 enify that 1 have read this application and Lame that Jct above information is
h buret. l agree m comply add herebyth ) omni d countyereordinanceslsof and stale lawser upon m QTY.
U%.
above
gcotioned i0nand hereby aumonrereoses. ivcaofthiscity toenterupon the
� uMwcmentioned prnpeny for inspection purposes.
(We) agree In save, indemnify and keep huntress the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDF,RS ANDS'AND WILL COMPLY WITH ALL NON -POINT
SO C REGULATI S.
�i 5-5-�1
S m reof Apipane/emrucmr ])are r
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by me Cupertino Municipal Cale. Chapter 9.12, and the Health and Safety
Cale. Section 255321a1"
❑Yes ONu
�i II tueaa�rymlice it or future building occupant use equipment or devices which
at
n contaminants as defined by the Bay Area Air Quality Management
.-�❑ye, E] No
I have rem. the hmax! materials requiremmeD under Chapter 6.95 of the Cali-
fornia Hwlth &Safety Gude, Sections 25505, 25533 ard 25531. I understand that if the
building does not currently have a pared. that it is my responsibility to notify she accounts
of the recommends which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL '
NF.LS
UP 200AMPS
211[-1AMPS
OVER10 MPS
SIGNS ELEC CAL
TEMP. METER OR P01-hINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OU ]'[,LOS - SWITCHES - FIXTURES
N BW RESIDENTIA L ELECTR SQ
PLUMBING
PERMIT ISSUA NCH
ALTER - DRAIN&VENT -( (EA)
BACK FLOW PROTEGE DEVICE/
DRAINS - FLOOR, ROOF, ARE 'CO fS.
FIXTURES-PER'I'RAP J
GAS - EA. SYSTEM.I INC.4 OUTLETS
GAS -EA. SYSHM OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GRIiASE TRAP
S17WER- SANITARY -STORM EA. 2W FE
WATER HEATER W/VENT/ELECIA
WATER SYSTEMi BEATING
WATER SERVICE
NEWRESIDENDALPLMB. SR, FT
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
A HANDLING UNIT(TO "CFCFM)
AIR H 'DLING UNIT (OVER 10,000 CFM)
EXIIAUST N( 1)
HEATING UNIT IWUIO BTU)
HEATING UNIT (OVL W,Wd
VFMILATION FAN (SING 'RI
BOILER -COMP (3HP OR 100,U
BOILER-COMP(OVER I W,OW
AIR CONDITIONER
NEW RESIDENTIAL MECH,
OFFICE
SQ,
31179
BUILDING PERMIT INFO
BLDG ELECT PL
U MECH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
El ADDITION
❑PLUMBINGRE-PIPE
El MULTI -UNIT
❑STRUCTURAL.
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
QBATH REMODEUREPAIR ❑ DEMOLITION
/VdfL�OTHER
COMMERCIAL
❑NEWBLDG/ADDITION
❑DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA S/SQ. FT
PAID
FEE MAY m 6 RECD
STORIES
BUILDING DIVISION FEES
PLANCHECK HE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date Receipt p
BUILDING FEE
FEE SEISMIC FEE
RLECTRICFEE
PLUMBING FEE -
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt e
ISSUANCE DATE