99090090APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC79
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHA'.
BUILDING PROJECT IDI N
BUILDING ADDRESS:
I OZ( I H-1 Lu L1� IZrb,
ZV-01%W
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under poot,mmr of Chapter 9 (err
with Section ]1000) of Division 3 of the Busincas and Professions Code, and my
I undersand my plans shall bo used as public records
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contrucmr's License Law for the
following reason. (Section 7031.5, Business and Professions Code Any it, nr county
which requires a permit to construct, alcor, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to File a signed statement
that he la licensed pursuant it, the prov lsious of the Conrucmis License Law (Chapter 9
(commencing with Section TMD) of Division 3 of the Business and Profession, Cade) or
that he is cxcmpl thmefrom and the basis fur the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty if
not more than five hundred dollars (SAID).
I, as owner of the property. or my employees with wages as their sole compensation,
will do the work, and the strucwre is not intended or offered for sale (See. 774, Business
and Profeeanma Coale: The Commeart's Users, Ixw taws not apply m oar owner of
popery who builds or improves thereon, and who doer such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale. If, however, the huilding or improvement Is scold within one year of comphorn, the
ownenbuilder will have the burden a] proving that he did not build or improve forpur-
pose of sale.}
1, as owner of the propmy, am exclusively contracting with licensed contractors to
ennalrml the pmject (Sec. 794, business and Professions Cade.) The Contractors U-
ase Law does not apply to an raw net of property who builds or improves notion, and
who contracts fur such projects with a comrations) licensed pursuant to the Contrecmea
License Law.
❑ I am exempt under Sec. B& P C for this reason
�3�°� Laves
❑ Consultant Fees Paid by Applicant (Initial)
)TY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP T02( �,
01-10(X _
OVER II
SIGNS ELECAL
SPECIAL CIE T/MI
TEMP. METER OR POLE INS .
POWIi 6. ?
SWIM G
)UT1.1'I S - S W ITCHES - FIXTURES
NEW RESIDENTIAL ELECfR SQ Ff.
Dal
caner WORKIER'S COMPENSATION DECLARATION
1 hereby attiren under Penalty of perjury one ol'the following declarations:
FlI have and wil l maintain a Certificate ofConscre to self -insure for Worker's Compem
sation, it, pm,idcd for by Section 3900 of he Labor Code, for due performance of the
work far which this permit is issued.
❑ I have and will maintain Worker., Compensation Insuranceas required by Section
3900 of the Lohor Code, for the performance of the work for which this permit i, Nsced.
My Worker's�C umpens I m Insumyce artier and Policy num} .-d-�. q p
Comers (Qjt�� NI \ Policy FROM
it l_
CERTIFICATE OF S EMOTION FROM E RKERS'
COMPENSATION INSURANCE
(This amtinn need not be comPlaed i(1he permit is forone hundred dnllma (SIM)
rates'
1 ndy ainthep rbumuncenflha work (or wM1leM1thispennitislemeA.InM1nll
notcon
Pl y ypersoni ymmncr be s pjec mlheWorken'Comcen-
O z sation L acs of Celifom .Dae
z APPIic
ti NOTIC ; PLICANT. IL after. ong thL Cendmule of L'xempnnn, you should
become subject to the Worker's Compensation provisions of the Labor Cale, you must
Cali fonhwi th comply with such provisions or this permit shall he deemed revoked
Uz CONSTRUCTION LENDING AGENCY
U O kforeby which that there issued( ec.i.1 leading agency for the performance of
W U the for which mit Pennh is ironed (sea. 3PNl, civ. c.)
p L) Lenders Name
IxndcrAddress
I certify that I have read this application and scam that the shove information is
Z c arca l agree m comply construction,and herebyth uth and county ordinances of and sore la enter
relating m QTY,
V z abovenmtionerand here by authorize representatives of this city menterupenthe
obnvcmee) go property furiaraily apurposes.
(We) ogres to save, indemnify anti keep hartnleav the City of Cmpenino against
liabilin gmems, costs and expenses which may in any way accrue agmina said City
necque embegmming oft' t
APPLICA T UNDERSTAN AND W .L COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building escalator store or handle h tcardnw material
as defined by the Cupertino Muni ,pnl de, Chapter 9.12, and the Health and Safety
Cade, Section 255320a
C] Yes
Will the applicant or future building occupant use equipmem or devices which
nit harandoua it contaminants as defined by the Bay Area Air Quality Management
District' /
Yes R+�
,it the tornadoes materials acquirements under Chapter 6.95 of the Cali
Safety Cale, Secti1, 505. 25533 and 25534. 1 undersand that if the
t curtenlly has tcnegL thmil is my rcapmsibility mpotify the mcupam
ata which the mitt to,isstrame oft Cenifieat of OCMmev.
PERMITISSUANCE \
ALTER-DRAIN&VENT-WA 'A)
BACK ROW PROTECT. DECE
DRAINS- FLOOR. ROOF. AREA, D.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASIVINDUS'I RL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANI'T'ARY - S FORM FA. 200 FI'.
WATER HEATER WNENT/GLECTR
WATER SYSTENITREATING
WATER SERVICE
NEW RESIDENTIAL PLMB.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ('10 I0,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST 'HOOD (W/DUCT)
HEATING UNIT (TO IM.MD BTU)
HEATING UNIT (OVER Hq," BTU)
VENTILATION PAN (SINGLE RP_SID)
BOILER -COMP (3HP OR IDEMR BTU)
BOILER - COMP (OVER 100.0100 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, FT
OFFICE
FEE
FEE
FF.E
JOB DESCRIPTION
VALUATION
SWITCHES REMODEL
�WL
ADDITION
BING RE -PIPE
1
S S
NIC
q CONT -1101.4
O
(. Z
3
WF
BUILDING PERMIT INFO
ENT
IMMING POOLS
BLDG
C;-
ELECT PLUMBMECH
L.Q LJ
FEE
FEE
FF.E
JOB DESCRIPTION
VALUATION
SWITCHES REMODEL
�WL
ADDITION
BING RE -PIPE
❑MULTI -UNIT
T UCTURAL
1
MODIFICATION
WF
CHIMNEY REPAIR
ENT
IMMING POOLS
' ODEVREPAIR
OT
EMOLITION
NEW BLDG/ADDITION
❑DEMOLITION
❑ FOOD SERVICE
/o 6
FWPZ` '_lr� J
BUILDING DIVISION FLEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
bull
PLUMBING FEE
MECHANICALFEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date
`?ISSUANCE DATE
- 2 s--'?�
VALUATION
OF STORIES
TYPECONSTRUCfION
1
WF
FWPZ` '_lr� J
BUILDING DIVISION FLEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
bull
PLUMBING FEE
MECHANICALFEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date
`?ISSUANCE DATE
- 2 s--'?�