30065APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
etc !`nneD'PDV n BUILDING - ELECTR
BUILDING DIVISION APPLICATION/PERMIT
OWNER :S
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 700 df Division 3ofthe Businessand Professions Crede, and my license is
in full prime and effect.
License�CJass Lit.p . g SO�
Dute{�j Contmcmr(fA
"I ARCHITE TS DIECLAATTIO
I makmatuml my plans shall he used as public records
1 OWNER -BUILDER DECLARATION
r�jy 0.C' a 1 heathy affirm that 1 min exempt I Inc Cunvucmr's Licence Law far the
�(31F following maum(Seefan)8315.Basinesa and Professions Code: Any city or county
41 u. ywhich requires a permit to construct. alwr improve, demolish. or repair any simcwre
¢
prior to its issuance, also requires the applicant for such pvriuorile as signed stmement
C 6 ithat he is licensed pursuant et the provisions of the Conoaetuts License Law (Chapter 9
0 (commencing with Section 7010) of Division 3 of the Business and Pmfessiom Code)or
II, c that he is exempt therefrom and the basis fan the alleged exemgion. Any violotam of
X m Section 703L5 by any epplleanl fora permit subjects the applicant m a civil penalty of
F Z Y not mom than Eve hundred dollars (4501).
_< 0 Las owner of the property. or my employees%no wages as their sale compensation,
See will dothe work. and the structure is not inumdedero(fired for sale (Set. 0004. Business
3 m and Pr w%xions Gide: The Cuntrocomis License Law does not apply to an owner of
property whit builds or improves thereon, and who does such work himself or through
his own employees, provided that such impmvanetns are not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
assame-builder will have the burden of proving that he did not build or improve for pm-
pau of sale.).
L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 70,14, Business and Professions Code:) The Conuactors Li -
comm Law does not apply ua an owner of progeny who builds or improves themes, and QT}:
who contracts for such Projects with a contractors) licensed pursuant to the Conaaclofs
License Law.
1 am exempt under Sec. _ - - . B & P C far this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cenificme of Consent to odf-insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
wart for is this peril is Issued.
i] 1 have and will mainmin Worker's Compensmion harnowce, as required by Section
37W of the Labor Code, for the performance of the work for which this peril is issurd.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy N.,
CERTIFICNI'I. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin section need not becompletcd it the permit is for ane hundreddollars ($HD)
or less.)
1 certify that in the performance of the work for whichthis )crit is issued, l shall
not employ any Patients any m �prp subjuuaNeWorkeriCompcn-
OZ satinet Wwcg ff },MaFi y(e
Z Appl'¢am nom— a
NOTICH TO APPLICANT. IL after making this ificate of Exemption, you should
?became subject o use Workels Compensation provisions of the Labor Cade. you MUM
feMwith comply with such provisions or this .it shall be deemed revoked.
CONSTRUCTION '.LENDING AGENCY
U 0 work
olDr lhmtherc isacd(Sec. ion leading agency WON, of
Newark for which this permit is issued )Secs 3041, Civ. C.)
p
Leat
U
} W Lenders Address
Iy I certify that 1 have react thisapplication
anarta state ces and
above information is
FZI curet'. l agree to rump
with all city and county ordinances and dace lows rclmingm QTY.
UZ building caiwaaction.and hereby anionic representatives of this city to enter upon the
above-mentioned property lav inspection "wi,s.
(We) agree m save. indemnify and keep harless the City of Cupenino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in asequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAYARDOUS MATERIALS DISCLOSURE I
Will the applicant or future building rwcupant slow or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and &dety
Code, Section 255320ay!
Cl Yet pNo
Will the applicant to future building occupant use equipment or devices which
emit hawalous air conmmimemis as defined by the Bay Arca Air Quality Manag rm nl
District!
E] Ye, ❑No
I have read the hernNous materials ri,airemetns ander Chapter 6.95 of the Cali -
foods Health & Safely Crile. Sections 25505, 25533 and 25534. I understand that if the
building dies not cogently lave a toward, that it is my reslamsibility to notify the anvpunl
of the requirements which Taus be mel prior to issuance of a CMificam of Occupancy.
Owner or ... hadzcd agent Date
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL,
PANELS
UPT02MAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TIEMR ME zR OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWHITHES- FIXTURES
SQ FT.
PERMIT ISSUANCE Y
ALTER -DRAIN&VEM'- EI FA)
BACK FLOW PROTECT. DA/
DRAINS - FLOOR. ROOF. AREA, V06
FIXTURES -PER TRAP /
GAS -EA. SYSTEM -I INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE NDUSTRL WASTIE IM RECEPTOR
GR PSE TRAP
SEWER -SANITARY-STORM G.2001717.
WATER HEATER WNENT/IELECTR
WATER SYSTEMTREATING
WATER SERVICE
NEW RESIDENTIAL PLM6. SQ. IT
MECHANICAL PERMIT
P12RMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO 10.000 CFM)
AIR HANDLING UNIT (OVER U).OW CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100.000 HILI
HEATING UNI'P (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP LAPP OR 100.0) BTU)
BOILER -COMP(OVER 1)0,0(X0BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
30065
� ZL
COMMERCIAL;
[-]NEW BLDG/ADDITION [_1 DEMOLITION
❑TENANT ❑ FOOD SERVICE
IhIPROVF.MENT
❑OT +t
If SQ. FT. FLOOR AREA $/SQ. FT.
FEE
VA"ROW"271996
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FLEE
PAID
Date Receipt p
TOTAL:
BUILDING FEE
FEF; SEISMIC FEE:
ELECTRIC FEE
PLUMNING FEE
MECHANICAL FEE
CONSTRUM [ON TAX
HOUSING MITIGATION WE
PAID
Dale Receipt
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
C1 ADDITION El PLUMBING RE-1IPH
❑MUL'rl-UNIT ❑STRUCTURAL.
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREYAIR El DEMOLITION
❑ OTHER
COMMERCIAL;
[-]NEW BLDG/ADDITION [_1 DEMOLITION
❑TENANT ❑ FOOD SERVICE
IhIPROVF.MENT
❑OT +t
If SQ. FT. FLOOR AREA $/SQ. FT.
FEE
VA"ROW"271996
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FLEE
PAID
Date Receipt p
TOTAL:
BUILDING FEE
FEF; SEISMIC FEE:
ELECTRIC FEE
PLUMNING FEE
MECHANICAL FEE
CONSTRUM [ON TAX
HOUSING MITIGATION WE
PAID
Dale Receipt