99080182APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY Q
CITY OF CUPE RTINO BUILDING - ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO I APPLICATION SUBMITTAL DATE
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
�115Fr11scn Zoe—Z�1lr-3ra93
I hemhy affirm that 1 ilm licensed under provisions of Chapter 9 (commencing .
WOO with Section]UOU)of Division3ufthe Business and PmfnsiunsCWe,a dray liccnu iz
1- m ton torte ann ercee O y
aUU License Cl as Li0.N SZ
Ndd fAllc Con DEC
AR hall W.TS DECLARATION
OZ N understand my plans shall be used as public records
4 R O� Licenced Professional
:4 :4 OWNER -BUILDER DECLARATION
ax CCLL •2 1 herchy affirm that I am eacmpt from the Convector. License lame Por the
W 3 G F following tens... (Section 70,11.5. Business and Professions Code: Any city or county
lel O y wmm� requites a permit m convect. alter. impm.c, demor.n. or rennir any xwctnrc
prior Ito id issuance. also requires the applicant tinsmith permit to Ne a signed statement
that he is licensed pursuant the previsions of the Contractors License Law (Chapter 9
D%t=0O (commencing with Section 7000) of Division 3 of the Business and Professions Cede) or
6 q a teal he is exempt therefrom and the basis for IM1e alleged ennaptiun. Any violation of
u: It Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($501)_
_� ❑ 1. as owner of the progeny. or my employees with wages as their tole compensation,
F+ veil l Jo the weak, and lheelfu rte, is um mmtlmormfered forsalc(Sec. 7044. Business
Taal - m and Prolession.s Code: The Comramrs License Law does not apply to an owner of
4' 3 p u,sc, who build., or improves thereon, and who docs such work himself or through
his own employees. Provided that such improvements are not intended or offered for
sale. If, however, the building err impmvement is sold within ane year of completion, the
er-builder will have the hnnlen of proving that he did not haild or improve for pmt
pose of sale.).
❑ 1...... er of the prnpeny, am exduively mnntmning with licensed cartmcunc to
construct IM1e project (Sec. 7W4. Business and Professions Ceske.) Ty. Contrane's Li -
,o Law does not apply to un owner of prnpeny who builds or improves thereon, and QTY,
who contracts for such projects with a comrectugs) licensed pmummt to the Commntors
Lice ce Law.
❑ I am exempt under Sec. B& P C for this reason
I )wncr Data
WORKERS COMPENSATION DECLARATION
1 hcrehy earn. under penally of pe jury one of the following declarations:
I have and will maintain a Certificate of Consent un ulf-insure for Worker',s Compere
satiml, as provided Isar by Section 3700 of the Labor Cele, for the performaae of Ne
work for which this permit is iswcd.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3]W of the LaMm Cute, for the petlamtance of Ihu wod for which this permit is issued.
M, Worker's Compensation Imumncc artier and Policy number are:
Cartier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thkssection rad not be completed ifthepemiit is fortmehundred dollarsH I M)
err less.)
1cenify that in theperformanceofthe work furwhich Ibis per is is ued, I shall
not employ any person in any manner so a5J=6{come suhie o Ne Workers Cme".
Q 2 "tion Laws of�liidt - Dmu_ ISS LLS^ 99
Z O Applicant v����� -
.N.
NOTICE 'I PLICAN'T: II::d¢r eking thio Ccniticale o1' Exemption, you should
bemuse subject to the Worker's Compemation provisions of the Labor Gde, you loud
undwith comply with such pr..voron, or this vannot hall he deemed (evoked.
a.
5z CONSTRUCI
move
i,a'IONLENDING AGENCY
V D I for
hieh hinnns
tba.it ii!<d(Ser. 30om lendlnt agency for the performance of
f• he aink for which this permit ix issued (Sec. 3119]. Civ. C.)
O U Lender'., Name
Isndcr'I Address
(, p, 1 certify Ihu have read this y Oil
and stale that the shove information is
Z commtlaamnaos , adhely thallcityandcountyorJircherev ve,maiscity W',,','cu,,,
src,,,. QTY
i .howhaddingconsmuctiamantyform vothonzerepm mtivex minis ci to nuupon IM1e
ahovnrnenlinnul property [nr itupeninn Ourpwec
(We) agree to rove, indemnify and keep harmless the City of Catarina against
1whilities,j idgmmnu, ends and cxpenus which rimy in any way acerae against said Cu,
in nxcqucnce d me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
I 0 i - Q -�r_a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hamnlous material
as defined by the Cupertino Municipal Code Chapter 212, and the Heath and Safety
Core, Section 25532(ap
(]Yes Ll No
Will the applicant or future building Occupant use equipment or devices which
it hamrdous air c rlaminants as defined Iry the Bay Area Air Quality Management
ane'?
❑Yas EJ No
I have read he ha.,mm us nmterials requirements under Chapter 6.95 of the Cali-
fornia H.Ith & Safety Cade, Sections 25505, 25533 and 25534. 1 understand that if the
bus turn, does not cummily have a reran.. dial it is my rcspomsibility to notify rhe occupant
of the �g9jv"i a wnirnyuZnc ural nnor m ia,�anm or a cmifiwte aroemp:,ar.
ELECTRIC PERMIT
PERMIT' ISSUANCE
APPLIANCIiS - RESI DEN ITAL
PANELS
UP TO 2M AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -Ie) XTURF,S
NEW RESIDENTIAL ELECTR SQ PL
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WAT'ER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF. AREA, COND.
FIXTURES -vu
GAS - EA. SYSTEM -1 INC. 4 OUTLET S
GAS - EA. SYSTEM OVER 4 (EA)
GREASOINDUSTR, WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WIVIIIELECIR
WATER SYSTEM/TREATING
WATER SERVICE
NEW'RESIDENTIALPLSIB. SQ. ET,
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IBODD CFM)
AIR HANDLING UNIT (OVER IOAW CEM)
EXHAUST HOLD(WMUC)
HEATING UNIT (TO 100,003 BTU)
HEATING UNIT (OVER 1L0,gM) BTU)
VENTILATION FAN (SINGLE, RESID)
BOILER -COMP (311P OR 1 00.000 BTU)
BOILER -COMP (OVL'R 100.(X10 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT
TOTAL:
OFFICE
FEE
FEE
T 2
NIC
RF. I� DENTIAL-
COMROhp
D SFDWL
L'�IBCiCHEN REMODEL
DADDITION
D PLUMBING RE PIPE
D MULTI -UNIT
BUILDING PERMIT INFO
BLL-DIGG ELECT
PLUMB
MECI
La L�
IF
❑
JOB DESCRIPTION
RF. I� DENTIAL-
��\\
D SFDWL
L'�IBCiCHEN REMODEL
DADDITION
D PLUMBING RE PIPE
D MULTI -UNIT
0STRU17FURAL
MODIFICATION
D INTERIOR
D CHIMNEY REPAIR
IMPROVEMENT
C] SWIMMING POOLS
U-IrATH REMODEVREPAIR
El DEMOLITION
❑OTHER
VV(
AITPM ej
COMMERCIAL'
DNEWBLDGIADDITION DDEMOLMON
❑TENANT DFOOD SERVICE
SQ. PT. FLOOR AREA
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date
TOTAL:
BUILDING FEE
FEE SEISMIC HE
ELECTRIC HE
_ PLUMBING kE
HOUSING MITIGATION FEE
PAID
j�'Date Remipl x
TOTAL: _ 701_
ISSUANCE DATE
2-
- (314