30790APPLICANTTO FILL IN INFORMATION WITHIN
BUILDING DIVISION APPLICATIONIPERMIT
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LICENSED CONT'RACTOR'S DECLARATIONQ.I,
I hereby affirm that I um licensed under provisions of Chapter 9 (commencing
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with Sectimtl00H)of Division 3 offle Business and Profession, CWe,amd my license is
in full tome end effect.
Liaise Class Lic. k _
Date Conductor
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APPLICATION SUBMIITAI
❑PLUMBING RE -PIPE .
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ARCHITIECPSDECLARATION
1 undendand my plans shall be used as public records
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Licensed Professional ,
OWNER -BUILDER DECLARATION
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1 hereby off nn that 1 am exempt from the Convector's License Law for the
following ramnar (Section 7031.5, Business and Professions Cede: Any city or county
which rryuitns a permit to construct, alteq improve, demolish. or repair tiny saucmrc
prior to lm issuance, also requires the applicant mrsuch permit,, file alignedstme
ELECT PLUMB MECH
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that he is licensed pursuant o nhc provisions of the Contractor's License low (Chapner9
(commencing with Section 70001) of Division 3 oiled Business and Professions Code)or
that he is exempt therefrom and the basis for are alleged exemption. Any violation of
Section 7011S by any applicant for a permit subjects the applicant to a civil penalty of
not it. than five hundred dollars ($510),
11 1, as owner orthe papdny,o my mnpl,,ydes with wages A thdirsole compensation.
Fwill
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do the work, andtuxurnturc is not intended proffered far sale (See ]IHJ. Business
and Professions Code: The Camescmrs License Law does not apply to an owner of
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properly who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are net intended or offered for
sale. IL however, the building or improvement is scold within one year ofcomplebr n, the
ov,mr-buitder will have the burden of proving that he did not build or improve for pur-
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pare,i ale.).
❑ 1, as owner of the pmpeny, am exdusively estimating with licensed conmmers to
x admal the p Jut (Sec. 7044, Business and Pmfessions Code) •the Comuctor's Li.
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cense Law does not apply In all owner of property who builds or improves thereon,and
who contract for such projects with .commands) licensed pursuant,, the Contractors
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License Law.
❑Iamexempt order See . ,B&P C for this reason
- Data
•Owner
WORKER'S COMPENSATION DECLARATION "
1 hereby affirm min a penalty
1have and will maintains leperjuryoneofthefollowing Worksm Ca
of Consent tdCodensue for Workers Compete
saiwork( to tion 37am
thi forby Section 3]lk) of the Labor Cede, for the performance of the
hick this permit is issued. .,
work have
and
❑ 1 have and will Worker's Compensation Insurance, as required by Section
odinmin
the Labmperfufor the performance of the work fee which this permit is issued,
Myof
My Worker's iCompensation Insurance carrier and Policy number a2:
Certia: Policy No.:
• CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ihhe pcmtit is forone hundrcddollars ($100)
ar less.)
1 certify that in the performance of the work for which this permit is issued,) shall
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net employ any person in any ....niter so us tet become sahjae, m the Workeri Compen-
sation Laws of California. Date
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a�become
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oLenders
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Applicant
NOTICE TO APPLICAN"D If, efair making this Cenificoe of Eiicmpti... yna should
subject o the Worker's Compensation provisions of Ne Labor Code, you must
forthwith comply with such provisions or this permitshall he deemed revoked.. ,
CONSTRUCTION LENDING AGENCY
Ihereby affirm thattbere iso cmtswxi0o lending agency for the performance of
the ..,it for which W s permit is issued (Sec. 31197, Civ. C.)
Name
Lendcr'x Address
1 certify that 1 have read this application and state that the above information is
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correct. l agree to comply with all city add county ordinances and state laws releing to
building construction, and hereby a uthorizareprsentatives oftbis city (center upenthe
above-memionul poi for inspection purposes.
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(We) agree tosave, indemnify and keep hamdess the City of Cupertino against
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liabilities, judgments, costs and exxdsaswhich may in way accrue against said City
in consequence of the panting of this permit. 11
APPLICANT UNDERS11kNDS AND WILL Y ITH ALL NON -PAINT
SOURCE REGULATh/.PS.
Will the applicant er fmure building nccupunt score rhnndle hnmrdrnw material
as i efred by the Cupertino Municipal Code, Chapter 9.12, nod the Hen1th and Safely
Code, Siction 25532(x)?
C] Yrs ❑No
Will the applicant or future building occupant use equipment or devices which
remit hazardous air cnmmcrinams as defined by the Bay Arca Air Quality Management
Distrix?
Dyes 1]No
I have rad the formations materials requirenents miler Chapter 6.95 of the Cdi�
Limit Health & Safety Cade, Sections 25505, 25533 and 25534. 1 undenmad the if nee
bolding dors nor carefully have a tempt, that it is my responsibility to notify the reception
of the requitement which must Is, men poor Int Issuance of n CeNreec of Occupancy.
Owner or submitted agent ^ Data
POINT PEN ONLY
Consultant Fees Paid by Applicant (Initial)
IIL17CFRIC PERMIT I FEE
APPLIA 'ES-RESIDIENTIAL.
PANELS
UPT0 200 AMP.
OVER IOW AMPS
SIGNS ELECTRICAL
SPECIAL CIItCU1TIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES..
SWIMMING POOL ELECTRIC
OUTLETS—SWITCHES—FIXTURES
NEW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
AITIER - DRAIN & VENT- WATER (
NEW
MECHANICAL PERMIT
SQ FT.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO I0,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT TO 100,000 BTU)
HEATING ON] F (OVER 100,0011 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER —COMP (3HP OR 100,000 BTU)
BOILER — COMP (OVER 100,00) BTU)
AIRCONDITIONER ,
NEWRESIDP.NTIALMECH. SQ. FT.
TOTAL:
I OFFICE
" JOB DESCRIPTION
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SANITARY NO,
APPLICATION SUBMIITAI
❑PLUMBING RE -PIPE .
❑MULTI -UNIT
EI STRUCTURAL
N/C
CONTROL M
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IMPROVEMENT
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
" JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
.❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE .
❑MULTI -UNIT
EI STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEURF.PAIR ❑DEMOLITION
❑OTHER %
COMMERCIAL
❑NEWBI.DG/ADDITION ❑DEMOLITION
❑TENANT FOOD SERVICE -
IMPROVEMENT
❑ OTHER
SQ.
JAN 16 Wig
3kur uuttHNNO
PLANCHECK FTE \
ENERGY FEE
FEE
BUILDING FEE.
PEE SEISMIC FEE
ELECTRIC PEE
PLOMHING FEE
MECHANICAL FEE
HOUS WG MITIGATION FEE
IPAID Data _ Receipt#
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FRGS
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Inspection Query for a Specfic Permit 2/19/97
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