30499APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO
1 hereby IF,. Nat I an licensed under provisions of Chapter 9 (comen
mcing
with Section 7100) of Division 3 afthe Business and Profession, Cexle. and my license is
io full forty avd
License Class Lic. q
Date — Contmemnyl—P L
BUILDING - ELECTRICAL'
PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT
PLUMPING - MECHANICAL.
EUILOING PROJECT IDENTIFICATION
O,
30491,
BUILDING ADDRESS:
(commencing with Section 70(0)ofDivision3 ofthe Business and Professions Code) or
that he is exempt therefrom end the basis for the alleged exemption. Any violation of
SANITARY NO.
APPLICATION SUBMITTAL DA
.sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose c f side.).
OWN R AME: PHONE .�71
CONTRACTOR'S NAM LIC NO:
❑ I, as owner of the property, an, exclusively contracting with licensed contractors or
N/C
❑
CONTROLq
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ARCHITECT/ENGI EER: IC
ADDRESS:
❑ Consultant Fees Paid by Applicant (Initial)
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1 hereby IF,. Nat I an licensed under provisions of Chapter 9 (comen
mcing
with Section 7100) of Division 3 afthe Business and Profession, Cexle. and my license is
io full forty avd
License Class Lic. q
Date — Contmemnyl—P L
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ARCHITECTS DECLARATION
I understand my plans shall he used as public raid,
Licensed PmFssmnal
.• .OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to consuacp alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pursuant to Ne provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70(0)ofDivision3 ofthe Business and Professions Code) or
that he is exempt therefrom end the basis for the alleged exemption. Any violation of
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Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500),
I] 1, as owner of the property, or my employees with wages as their sole comiensaticn,
will do the work, and the stmenum is not intended creffeted for sale (Sec, 704Q Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvemems are not intended or offered for
.sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pose c f side.).
❑ I, as owner of the property, an, exclusively contracting with licensed contractors or
onsuuct the poiea (Sec. 7044, Business and Professions Code:) no Contractors Li-
QTY
cense Use does not apply to an owner of property,who builds or improves thereon, and
who ese'raca 1-1 such projects with a contortions) licensed potation to the Contractors
License Law. -
I] 1 am exempt under Sec. , B & P C for this reason
Owner Data
_
WORKER'S COMPENSATION DECLARATION
I hereby inform under penalty of perjury one of the following declarations:
I haveand will maintain a Certificate of Consentto self -insure for Worker's Compen.
don, as provided for by Section 3700 of the Labor Code, for the performance of the
j for which this pento is issued.
have and will maintain Worker's Compensation Insurance, as required by Section
AJ
W of the Labor Code, for the
performance of the work for which this permit is issued,
My Worke$FCc to cation Inyxance comer and Policy nyp��,are:
Came: y]_Ol� Policy N0: 6C/ ` / Y P
CEBTIICATE OF EMPTIONFROM WORKERS'
O
COMPENSATION INSURANCE
(This maturated not be completed if the permit is for onehundreddollum ($ IOo '
or loss.)
I cenify than In the performance blow work for which this permit is issued, I shall
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not employ any Person in any manner so as to become subject to the WorkersCompen-
cation Laws of Citho mis. Dam
Applicant
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abecome
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NOTICE TO APPLICANT: If, after mailing this Certificate of Exemption, you should
subject to the Worker'a Compensation previsions of the Labor Code, you must
foMwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTIONis.rdoLENDINGAGENCY
fhGm that there is sued iSuction lending agency for nbe performance of
I for which
the dworken's N r which this permit is issue.) (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
1 t:cnify that I have rear) Ibis application and state that the above information is
correct. I agree to comply with all city aril county ordinances and mane laws relating to
building combustion, and hereby andimb. represenmOves of this city to enter months
abmvo-mcntioned property for inspection purposes. '
QTY
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way second against said City
consequence of the granting of this permit. /
'APPLICANT
(LICA FGUyNTTI( Ow /NV IyJL . C( MPLY W�T�/ALL N NT
IL.
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Will the appher m or More building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter, 9,12, and the Health tad Safety
Code, Section 25532(a)?o
❑Yes ,
Will the applicant oris(mune building occupant use equipment or devices which
emit hazardous air cnnmminams os defined by the Bay Area Air Quality Management
District?
❑ Yes (YlSa
I have read the haduall 'skmaterial raq . an dc'
Chapter 6.95 of the Ca1i-
fomia Health &Safety Code, Sations 25505, 2j�3Mand 25534, I understand ohm if the
buildl,g rXE�lgt curzentLy have a tey�t, phut itis �I� s� nslbil'nytamtify Uearupann
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — S W ITCHES — FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER— DRAIN & VENT— WATER (EA)
GRAINS — FLOOR, ROOF, AREA, COND.
FIXTURES — PER TRAP
GAS—EA. SYSTEM.I INC. 4 OUTLETS
GAS— EA. SYSTEM -OVER 4 (EAG
OREASFIINDUSTRL WASTE INTERCEPTOR
SEWER—SANITARY—STORM EA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER I0,000 CF
EXHAUST' HOOD (W/DUCp
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER—COMP QHP OR 100.000 BTU)
BOILER—COMP (OVER 1110,00OBTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH.
OFFICE
SQ. ET.
BLDG ELECT PLUMB M C
❑ ❑ ❑
FEE
JOB DESCRIPTION '
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
C] ADDITION El PLUMBING RE -PIPE
El MULTI -UNIT ]STRUCTURAL '
MODIFICATION'
] INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
El BATH REMOD PAUL[]D OLITION
[]OTHER
0 {Q
COMMER IA ,
El NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FLIT .O tr EA $ISQ. FT.
EEE OVP 12 1996
CIS Y Ul L.UYL I HYV
PLANCHECK FEE
ENERGY FEF.
GRADING FEE
SOILS FEE
PAID
Date Rccelptq
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING An DGATIO'.
PAID
Date Receipt,
TOTAL:
DATE