30122TO FILL IN INFORMATION WITHIN RED LINES
BUILDING DIVISION APPLICATION/PERMIT
IILDINGAUDRESS: }
5
LICENSED CON'TRAC'MR'S DECLARATION
1 hereby affirm but 1 um licensed under povisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Bminess end Pmfusiena Cale. and my license is
in full force and effect. -
License Class Le. N
Dare - - Contractor
ARCHITECT'S DECLARATION
1 understand my puns shell be used as public records
PEN ONLY
IING - ELECTRICAL
IING - MECIIANICAI.
ROJECI' IDENTIFICA'VION
n
LIC NO:
❑ Consultant Fees Paid by Applicatit (Initial)
)TY ELECTRICPERMIT FEE
eW OWNER -BUILDER DECLARATION
ssy�yTT� 1 hereby nffrm that 1 am eschom mala the Coal ... the. License Law far the
W 3 L U following rexsan. (Section ]lD L5, Business and I'nslbssiens Calc: A city m manly
F = LLO which require. x permit to construct, alter, improve, demolish, or r any slrunum
prior to its issuance. also requires theapplicam fo hpermi ofil signed statement
G that he is licensed pursuant to the provisions of the tact r' Lnm ltaw (Chuper9
(commencing with Section 700B of Ur out elshe 'in a eficomns Ccalc)nr
d C that he ix exempt iherefrmo and t I'ur ra x ,mina 'isthmian of
_ 0.y Section 5 ]031by any tipplictini fn pmmii s is t .,plica o a civilis mdty of
T mare than five hummed dollars(S )
Sp ❑ 1, as owner of the property, or my ith wage thei embpematlimi,
will dosbe work,and Nemruct... is lime Woioffe far ec: 7064#. Busiss
nofesalm s Code: The Contractor's License L d nit to an owner
d Pmor
d property who huilds or improves thereon, and as , sac oik himself or through
his own employees, provided that such imps nix are it intended or nficmd for
sale. IL however. the building ar improver sold wi one year of completion, the
-builder will have the barren of pmemg that he tad nos build tar improve fur pi n-
s owner of m6 me
exclusively contacting with licensed contractors to
v smmT the project (Sea. ]044, Business and Professions Cedea The Comoo,lea's Li-
a c om Law does not apply to an owner of property who builds (ir improves thereon, and QTY.
who contracts for such projects with a contranot(.) licensed pursuant to the Contractor's
License law.
um exempsud Sc. ,B&PCfar this match
caner Dam
WORKERS CO PF.NSA'110N DECLAIIA'I'ION
I hereby ufftrm under penalty of perjury one of the following decl.retions:
L] I have and will maintain a Cenific.le of Camam to sdLinsuo: for Warkc/s Compete
action, a provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Com,enamion Insurance, as required by Section
37W of the Labor Code, far the performance of the work for which this permit is Is t,csi ,
My Worker's Compensation Insurance carrier and Policy number arc:
Come, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the panni, is for he hundred dollars S 1 no _
.Ails.)
I certify That in the performance mom work fer which this permit is issued, l shall
net employ any person in any manner an as to become subject m the Workers' Cmnpem
0Z sation laws of California. Date
O Applicant -
NOTICE ID APPLICANT, IL after making this Certificate of Exemption, you shoulJ
a' become subject m the Worker's Compensation provisions of The Labor Code, you must
forthwith comply with such prm'ns lo or this permil shall he deemed revoked.
Q
=z CONSTRUCTION LENDING AGENCY .
U 0 Thereby affirm that there is a construction lending agency for the performance of
", F the work far which this .i, is issued (Ser. IMD, Civ. C.)
0 U Lender', Name
Lendefs Address -
1 certify that I have read this application unit state That the above information is
aiisF y toned 1 agree to comply with all city and county ordinances rill state laws minting to QTY.
U building construction, and hereby authorize representatives ofthis city to enmrupn The
above-mentioned prnpenY for inspection purpne'es,
(We) agree to save, indemnify and kee, hatmless the City of Cupenino alliin.'
liabilities, judgmen¢, costs and expenses which may in any way accrue against said City
in consequence of the gaming of this peaml.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALL NON -POINT
SOURCE REGULATIONS,
i.
Signature mApplicantlCommcmr Date
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant or future building occupant store or handle hazallous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the IIea1'h and Safety
Cade, Sat ion 25532(x)?
❑Vex 0 N I
Will the applicant or future building occupant use equipment or devices which
-
a hmaNuns air contaminants as defined by the Bay Amu Air Quality Management
istrict?
❑Yes r9No I- - .
I have rust the huvmdous materiels requimmetns or&, Chapter 6.95 of the Cali
forma Health & Safety Code. Sections 25505, 25533 end 85341 understand! that if the
building does ton currently have a mann'. that it is my responsibility to notify Ne occupent
of the requirements which most be met prior to issuance of a Certificate of Occupancy.
Owneraruuthnriaid agent - Data
PERMIT ISSUANCE
APPLIANCES -R17S
PANELS
UPTO 211(1 AMPS
201-I000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE. INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR
PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VINT- WATT➢� (
BACK FLOW PROTECT. DEVICI?Sy
DRAINS- FLOOR, ROOK, AREA, CONI
FIXTURES - PER TRAP
GAS -EA. SY.S'1'IiM-�11 LETS
GAS-FA.SYSTI: VE )
GRHASETRAP s p \
SH W ER - SANITARY - SMRI 13 .
WATI7R HEATER WNENT/ELECIR
WATER SYSTM/1'REATING
WATER SERVICE -
NEW RESIDENTIAI. FLAIR.
v
SQf..
TOTAL.:
FEE
MECIIANICAI. PI7RMIT
PERMIT ISSUANCH
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO I0,000 CPM)
AIR HANDLING UNIT (OVER 100M CPM)
EXHAUST HGOO 1 W/DUCO
THAI [NO UNIT (TO 100,010 BTU)
HEATING UNIT (OVER 100,000 RTU)
VENTILATION PAN (SINGLE RESID)
HOILER-COMP (NIP OR I W,010 BTU)
BOILER -COME (OVER 100,000 BTU)
en"""H 3 012
r\"iq V
JOB DESCRIPTION
RESIDENTIAL:'
I. .
❑ KITCHEN REMODEL
Gil ION'
❑ PLUMBING REPIPE
MULTI -UNIT
❑STRUCTURAL
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT '
❑BATH RFUQWVkEPA
El DEMOLITION
•y�IR
'OOTHER I'C7COMMERCIAL,CI0L,, v
❑ NEW BI.DG/ADDITION
❑ DEMOLITION
El TENANT
❑FOODSERVICE
IMPROVEMENT
❑OTHER,' -
-
SQ. Fr. /FLOOR AREA
S/SQ. ET.
JUL 01 1996
CITY OF C0PVP'0Afr)
STORIES 'TYPECONSTR
,t
r
OCC, GROUP APN
BUILINNO DI VISION FE
PLANCHECK FUE' .-
ENERGY FF.E
GRADING Ff:C
'SOILS FEIi
FL PliK
Date Receipt#
'AL;
BUILDING
FEE SEISMIC FT..!
HLECTRIC lilt f
PLUMBI ' FEE
MECHA [CAI, FEE
CONST UCI'ION TAX
HOUSI GMITIGATION FEE
t
PAID
Dom Racip p
TOTAL:
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL: ISSUED BY: