99120053APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
BUILDING -
CITY OF CODII VERTINO
nUli.nlwG VISION APPLICATION/PERMITsir �` soil no"cL MECHANICAL'
N
CONTACT:
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Amtlon 91010 of Ulmsion 3 of (he Bush... amd Professions Cale, and my license is
in full farce and eli'esa.
Liernu Clan Q� Lie.0
Du¢To's Cuntr or
ANCHITBCI'5 FECLARAI ION
1 understand my plans shall be used an Public records
Limmed Pn lesional
OWNIiR-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Comewasex License law for the
following reamn. (Section 7031.5. Business and Professions Code: Any city or county
which rcgtdrw a permit to cmutraCt. alta% improve, demolish, ore repair any smame
prim to its issuance, also requires the applicant for such permit ret file a signed.valt, end
that he is licensed purtuant to the prevision of the Conuacmrs I.imma, law (Chapter 9
(eommeneing with Section 700) of Division 3 of the Business and Pwdjcdsiaas6sls) or
(hut he is exempt therefrom and the hams for the alleged exemption. Any violadnn r.1'
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of
not more than five hundred dollars (5508).
O L as owner of the properly, or illy employees with wages as their sale contpensaion.
will do the work, and the strvetum is not Intended or mitred Poli sale (Sec ](144. Business
and Professions Code: The Contractor's License Law does not apply In an owner of
property whir builds or improves thereon, and who docs such work himself a through
his own employees, provided don such Impmvcmcntd am not intended or Offered for
one. If, however. the building or improvement is sold within ane year of completion. the
owner -builder will have the burden of proving that he did not build or imprevc for pur-
,on of sale.).
n 1, w owner of (he property, um exclusively canmcling veldt Iirewerl contractors it,
ansqua the project (Sec. ]IH4. Buzinecs and Pvdessians Crde:) The Gon(memr a Li-
ss Law does not pply to an owner of propeny who builds or impnwes thereon, and
who %.... (.d,. fit, such projcros with a eontrumogs) Iianvod pasmom ret the Council
license law.
I am exempt under Sec. ,B&PCfor this resists
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby oliirm under Penally of perjury one of the following declarations
n 1 base and will nourne n a Cenifocne of Comm�raosclf-o m e for Workers Compen-
sation, w provided for by Satins 370X1 of the Labor Code, for the perboarro c 01 the
work for which this Permit is issued.
I have and will maintain Worker's Compereution Insurance. as required by Section
3]W of the Labor Calc, for me perfonnanm ofthe wort for which this Permit is Issued.
My Worigs Cnm�ten titin Insurance evmier and Policy hunter are:
Cartier: IS OZZOOID Policy No.:
CERTIFICATE OF EXEMPHON FROM WORKERS' -37)
7GOMIENSA'I'ION INSURANCE gi/1
ffbassectionacedionfecomplicirdifinepermit isfcrrncbandrNdollars(Sllp)
le s.)
I cenify that in the pc,fonmmn of the work Iia which this permit is issued. I shall
not employ any wr.na in any manner so as to become subject m the WorkersContpen-
Z cation Laws of Colifomia. Date
z Q Applicant i
HIM ICH 10 AI'PUCAN'I': If, alter, looking this Cee ificam of Escmpliun. You should
I•' ^ become mbjec,,, the Worker's Compensation previsions Of the Labor Gdcs you must
Wforthwith comply with such provisions or this permit shall he deemed invoked.
0
Ua' Cinthe isacarNwdom lending agency
Q (hereby ethos thin them isacon>tmedon lending agenry for the performance of
[A H the work far which this permit is issued (Set. 3097, Co, C.)
O U [,Oiler's Name
}Lender's Address
G 1 cenify that 1 have rtai this application and stale Lha the above information is
tilin cmmit.I agreetoean.fly with all city and county ordinances and state laws oi 1.
U bolding consmadon. and hereby aumaiee represcmmives of this city m enter upon the
above-mentioned property Ino impaction purposes.
We) agree to save, indemnify and keep hamlesa the City of Cupertino against
liabilities, judgment., costs and expenses which nmy in any way acaue against said City
as amuyuence I the gmming of this penial.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS,
Slgaaure of Applicant/Co newh r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcam nil future building occupant store or handle h,ourdous nm¢rial
as deGdal by the Collection Municipal Code, Chapter 9.12, and me Health and Safety
Cale, Section 25532(0)?
GYc Ni,❑
Will the applicant or future building occupant use equipment or devices which
emit hamrdow sir Omoamiwnls as definN by the Bay Area Air Quality Management
DoIncfl
❑Yes 0 N
1 have lead the hamrdous nationals requirements under Chapter 6.95 of the Cali-
fomia Health & Safety Cs ts. Sections 25505, 25533 and 25534.1 understand (ha( if the
Wilding does not currently have a basal, mat it is my rwpOnsibility in notify the necupant
of the acquirements which nowt be incl prior to issuance of a Cenificute of Occupancy.
1*47
COM'RACfOR'S NAME: LIC NO:
NIC
❑
CONTROL#
ADDRESS:
73 iiltg e ti
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INTO
BLDG E1L 1CI� PLUMB MECH
❑ L ❑ ❑
QTY ELECTRIC PERM IT
FEE
JOB DESCRIPTION
RESIDENTIAL'
O SFUWL O KITCHEN REMOUEL
[IADDITION O PLUMBING RI: PIPE
.GMULT[.UNI'r OSTRUCI'URAL
MODIFICATION
Cl INTERIOR OCHIMNEY REPAIR
IMPROVEMENT C)SWIMMING POOLS
G BA'T'H REMODEIAREPAIR ODEMOLITION
OOTHER
PERMIT ISSUANCE
APPLIANCES -RESIDEND EAL
PANELS .,
r UPT0200AMPS
201-I110AMPS
OVER 1000AMPS -
SIGNS ELECTRICAL.
SpEC1A1. CIRCUIT'/MI$G.
AN
TEMP. M EDiR OR POLE I NST.
OMM R IA
O NEW BLDGIADDIT'ION ❑DEMOLITION
[I TENANT 0FOOD SERVICE
IMPROVEMENT
-
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUT SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS. SQ FT.
SQ. Irl'. FLOOR AREA
SISQ. FI'.
T (YI'AL:
QTy.. PLUMBING PERMIT
P12RMI'L ISSUANCE.
ALTI7R -DRAIN & VENT- WATER (EA)
Ole VALUATION
,
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
STORIES
TYPE CONSTRUCFIOC
FIXTURES - PER TRAP
GAS - EA. SYS'1'EM- I INC. 4OUTLETS
OCC. GROUT'APN��
GASB -IEA. SYSTEM-OVER4 BE)
GRFASUINDUSTRL WASTE INTfRCEPfOR
ItU11.DINC DIVISION fl?GS
HEI3ASE TRAP
PLANCHECK FILE
SFWI:R -SANI I'ARY- STORM IEA, TOP FII
-
IiN1iRGY FEE
WAFER HEATER W/VI;NT/ELEM R
GRADING FEE
WATER SYSTEM/IRERI'INC,
SOILS FEE
WATER SERVICE
PAID
)am Bcucipt%
NEW RHSIDEN'FIALI'hMB, SQ. IT
TOPAL:
UTAL:
I3l1ILU1NG 0iE
QTY. MECHANICAL PERMIT
FEE
SIiIShBC Fol[
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE`
MECHANICA-, ,
AIR HANDLING UNIT (TO 10.000 CFM)
AIRHANDLINGUNI'1'(OVER 10,000CPM)
CONSTRUCTIONTAX
EXHAUST HOOD (W/DUC)
HOUSING MITIGATION FEE
HEATING UNIT (TO HV,000 BLU)
HEATING UNLF OVER 100.000 BTU)
PAID --
Dam Rcculpltt
VENTILATION I'AN(SINGLE RESID)
BOILER -COMP OHP OR 10b.000 BTU)
TOTAL:
BOILER -COM I'(ov ER Ig1,INN1 13'1 U)
AIR CONDITIONER
ISSUANCE DA'I'I;p
r
/ 2-,
ISSUED 13Y: C/
NEW IPSIDENFIALMECH. SQ. W'.
TOTAL:
OFFICE