30172APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING DIVISION
10lihiY:LaIR
APPLICATIONoTERMIT
IIRtlsYap
Sl f, IJ �� ❑ Consultant Fees Paid by Aoolicant (Initial)
LICENSED CONTRACTOR ti DECLARATION _ QTY.
1 bercby affirm Nat 1 am licensed under pnwisim, of Chapter 9 gnmmaroo g
FON with Seeme.70(n)ZADivisi�n Jofthe Business and Profcsdnna Cadc.,nd my license is
FWO in full force and ,ffe
U F' Licenl Lic. p
MQ6 Dme Commcmr
ARCHITECf:S DECLARATION
Z O N N Z [understand my plans stall be used as public records
OZ -o
F 4 L W Licensed Professional
,iy.%..3 OWNER -BUILDER DECLARATION
Wo 6 1 hereby affirm that 1 um exempt from the Contractor's License Law for the
6 U following reason. (Section 7031.5. Business and 14ofceslons Cde'. Any city or county
ale F which requires a permit to conslma, alter, improve, demolish, or repair any stmcmre
P" O prior to its issuance, also requires the applicant for such Permit to file a signed statement
ythat he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
WAGO (commencing wiNSection]IllMpof DivisionJof the Business end YmfcxsionsCde)or
d ey that he is exempt Iherefmm and the basis far the alleged exemption Any violation of
NSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than live hundred dollars (SIM).
SSCE] 1, as owner of the property, or my employees with wages as meirso)c campenwtion,
will do the work, and the s mcmrt is not intended or offered for sale (Sec. ]010. Business
tail t: will
Professions Code: The Coun ureas License Law docs not apply to as owner of
d 3 — propeny who builds or improves thereon, and who docs such work himself or through
his own employees, provided that such improvements art not Intended or offered for
sale. If, however, the building or improvement issold within one year ofenmpletion, the
owner -builder will have the hmden of proving that be did not Mild or improve for par,
Fare or sale.).
1, as owner of the propene, am exclusively contracting with licensed contractors ser
co me t the pruject (Sm. 70U. Business mW Pndexsions Code q The Contractor's cerise Law does not apply to an owner, of property who builds or improves thereon, and QTY.
who contracts for such projects with a contractons) licensed pursuant to the Commnor'e
Liccoso Luw.
F) I am excntpl under Sec. ,B&PClirt this reason
Owner Due
• WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury one of the following dedart
I have and will maintain n Coma iecte of Consent to self -insure far Worker's Compeer
sation, as provided forty Seel on 370C,Code.of the L N)r Ce, for the pert nuance of the
work for which (his permil k i.mcJ.
NI have and will maintain W'orker's Compensation announce. as rtquied by Section
J]fM of the Labor Code, for the performance of the work for which this permit is issued.
Me Workers.Cmnrenmtioalaxumnce catrier and Policy number, 4c: ,. x21#•119 w
CERTH9CA'I'1: OF EXEMPTION FROM WORKERS'
C(1MPENSATION INSURANCE
(This #Betio need not be completed from arnial is fomne hundred dollars (SIM)
1 certify thal in the performance ofthe work for which Nis permit is issued. ),hall
not employ any power in any manner so as to become subjecun the Workers' Compen-
0 Z sudors Laws of Culifomla. Date
O Applic:mt
NOTICE TT) APPLICANT: If, aIle, making this Certificate of Exemplum, You should
a ,r, become subject m the Worker's Compensation provisions of rhe labor Cache , you must
foramina comply with such prevision%or this permit shall be decmd revoked.
Q
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nerc is s ed (Seed 0 tenth7,Civ. C) agency for IM1e performance of
W the work for which this permit is issued (See. 3097, Clv. C.)
0 V tenders Name
Lcndc I comityAddress
1 ecnee that I have red thirty an coon and stale Nat the above ws mlatinn is
fZ cumin. I agree to comply with all city and county ordinances and state laws rupong a QTY.
L abovengcsfloned iomart hereby mnhonp rposes wives of this city nt trots upon the
about -mentioned propene lin emnifyi an keep hs, I
(We) agree m save, indemnify and keep y in an the City r Cupcnino again
st
liabilities.
quer a ofn ecosts and expenses which may in any way accrue against sail Cal
It
APPLICANT
of thegranting of this per mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicam"Commoor Date
HAPARDOUS MATERIALS DISCLOSURE
Will the applimnt ser fumrt building occupant sere orhandle harmonic; mamal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code , Section 25532(#)°
❑Yes 0 N
Will the applicant or future building «cupam use equipment or devices which
emit h teallous air contaminants as defined by the Bay Area Air Quality Management
Distinct?
C] Yes ❑Nu
1 have red me haemdous aerials requimmcros under Cooper 6.95 of the Culi-
fomia Health & Safety Code, Sections 25505. 25533 and 23534. I understand That if the
building Jets not currently have a teemnl mat it is my mxpuroibility to notify the compact
of the mquirtmenb which must he mel prior to issuance of Ccr ificae of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP, METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECfR SQFT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VI?NT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
AS - FA. SYSTEM OVER i (EA)
GREASEINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WNF,NT/ELECTR
WATER SYSTEM7REA'TING
WATER SERVICE
NEW RESIDENTIAL PI.MB. S0. FE
TOTAL:
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO BLOCK) CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOLD(W/DUCT)
HEATING UNIT CIO 100,000 BTO)
HEATING UNIT (OVER 100,000 BTU)
VENT'IIATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR H10.00M BTU)
BOILER - COMP(OVER I TKLOM BTU)
AIR CONDD'IONER
NEW RESIDENTIAL MSCI I. SQ. FT.
OFFICE
JOB DESCRIPTION
RESIDENTIAL,
❑SPDWI.
'°nn1"
— 3 017
[I PLUMBING RE -PIPE
❑MULTIUNIT
SANITARY
NO.
APPLICATION
SUBMITTAL
❑CHIMNEY REPAIR
IMPROVEMENT
NIC
❑
❑ BATH REM EL/R IS
[]jI MOL i
CONTROL%
(�
O�
BUILDING PERMIT INFO
COMMERCIAL:
BLDG
El
Lu_Qc
M�ECHj
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SPDWI.
❑ KITCHEN REMODEL
❑ADDITION
[I PLUMBING RE -PIPE
❑MULTIUNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REM EL/R IS
[]jI MOL i
DOTTER 11
COMMERCIAL:
[I NEW BLDG/ADDITION
El DEMOLITION
❑TENANT
❑ FOOD SERVICE
, IMPROV17MENT
SQ, FrAz!OR ARI!
AID
FEE JUL 18 a+ -D
PLANCHECK FEE
ENERGY FEE
GRADING FEE
5011 S ITT':
PAID
Date Receipt#
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC HE
PLUMBING FEE
MECHANICAL FEE
VSQ. FT
TYPE CONSTRUCTION
I CONSRUCION TAX I
I HOUSING MITIGATION FEE I
PAID
Dale Receipt#
ISSUANCE DATE: