99080111APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
Consultant Fees Paid by Applicant (Initial)
IIAZ RDOUS mXTFRIA1.S DISCLOSURE
Will the applicant or Enure handing ec,risea ware or handle hueardoos material
as defined by the Cupertino Municipal Calc, Chapter 9.12, and the Health and Safety
Code, Section 255321.0!
❑Yes ❑Nn
Will the applicant or future building occupant use equipnmnt or devices which
.it hmnNous ter conmminanu as defined by the Bay Arca Air Quality Management
District?
❑Yea 0 N
I have mad the hvurdmo n medals mquinmems under Chapter 695 of the Cali-
fomia Health & Safery fide. Sections 25505. 25533 and 255M. I undersuml out if the
buiding does not cancndyjae a tcnau. tnmy re msiblity to notify the occupant
n,
the anuomems II must lw me laCenireme of Ocvuiaruy.
ELE(-TRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
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• LICENSED COM RACfOW5 DECLARATION QTy
PERMIT ISSUANCE,
I hereby affirm dot 1 am decrocd under provisions of CmIne, 9 (commencing
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with Section 7a)(t)of Division 3of the llunness and Profesx.nns Codes lmdmy lice., is
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in full tome and effect.
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License Class Lic.N
Ilam Conn.'
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ARCHiIECI"S DECLARATION
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I understand my plans shall he used as public Worst,OZ_❑
PAIR
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Licensed Prafessi... I
PLUMBING PERMI FEE✓{
OWNER BUILDLR DECLARATION
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1 hereby am an that 1 am exempt from the Commit License law for the
ed
s Nc: Any city or county
following mason. (Section 703 I.S.Business usiness and PmfessinnG
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which requires a permit to constrict. alter, improve. demolish, or repair any structure
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priom rits isemmca also requires the applicvm lonneh permit or file aligned mn Nantm
� y,
that he is licensed pursuanOodmimvlsionsofthe Contractors License law(Claapterit
GREASUINDUSTRL WASTE INTERCEPTOR
(commencing with Section 9000)of Division3 ofthe Businessmtd PrefexsionsCode)"rt
C ce y
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031 S by nay appicaut Fore permit subjects the applicant m a civil penally of
12 y 135
not rams.11agglive hundred dollars (5501
WATER HEATER WNeNT!ELEC R
[Qf farm property or my employees with wages as their sole compensation.
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will do the work, and the structure is not intended or offered for sale (Ser. )IFpI. Business
IWil an
and Prafeesia b Care, Hic Contractors License Law doer not apply to an owner of
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propeny who builds or improves thereon, and who dens such work himself or through
NEW RCSIDENTIAh PLMB. ^ SQ�FT.\\ I I
his own employees, provided that such impmvemmnts are not intended or offered for
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sale. IL howeverthe building or improsument is sold within one year of completion, the
TOTAL:
cr-buldor will have the burden of proving that he did not build or improv, for Pur-
pum of sal,.).
❑ 1, a% owner of the propeny, am exclusively contracting with licensed comments to
common the project (Sec. ](H4, Business and Frofessiom Code:)The Conor abonx la-
scLaw does not apply to an awnet of propery who builds or improves bacteria, and QTY.
whoamma.horsuch prnjccn with a c.lo un(s) licensed -uamm B¢ Comment',
Lieens, Law.
1 am exempt underI am coder S�, B & P C load, na,..B & P C for this reason
�O:am
WO EWS COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury one of Ne following declarations:
[ have and will maintain a Certhicam of Co neem to self -insure for Worker's Compen-
emion, a, provided fill by Section 3700 of the Labor Code, lin the Ismoamamx of the
work for which on, permit is issued
n 1 have and will maintain Workers Compensation Insurance as required by Section
3901 of the Lubur Code, for performane of the work lot which this permit is issued,
My Warner Compen u tion Insurance carper and Policy number are
Cur e,. Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fl'his w cues recd not be cumpletcd if Ibe permit Is 1'n. one omon I doll. n ($,W)
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I em ify that in Ne performance of the work far which this permit is issued. I shill
ant employ any Lenon in any manner so as to become suhjen m the Workers' Compcn-
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..tion Luws of California Date
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Applicant
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NOTICE TO APPLICANT. IL agar making this Certificate of Exemption, you should
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become subject to the Worker's Compensation provisions of the Labor Code, you most
lorliwith a ild, widunch Provisions nr this pernit smell be deemed revoked.
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CONSTRUCTION LENDING AGENCY
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affirm that there is agency for Performance of
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issued (Set.
the work for which this permit is iswed (Seas 309). Cie Cd
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Lender's Address
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cenify that 1 have mad this above applicannn and state that the we information is
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carer. I ngme m comply with all city and annoy ordinances and Stem laws miming w QT'y
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huildingeamemaction, and hereby authoriu representatives of Nisciry to enter upon 'he
above-mentioned propeny for inspersion purposes.
(We) agree to ave, indemnify and keep harmless the City of Cupertino against
Intolhies,jndgmenu, costs and expenses which may in any way accrue against said City
in onscyuence of the granting of this permil� //
APPLICANT UNDERSTAI§DS AND L LY WITH ALL NON POINT
IIAZ RDOUS mXTFRIA1.S DISCLOSURE
Will the applicant or Enure handing ec,risea ware or handle hueardoos material
as defined by the Cupertino Municipal Calc, Chapter 9.12, and the Health and Safety
Code, Section 255321.0!
❑Yes ❑Nn
Will the applicant or future building occupant use equipnmnt or devices which
.it hmnNous ter conmminanu as defined by the Bay Arca Air Quality Management
District?
❑Yea 0 N
I have mad the hvurdmo n medals mquinmems under Chapter 695 of the Cali-
fomia Health & Safery fide. Sections 25505. 25533 and 255M. I undersuml out if the
buiding does not cancndyjae a tcnau. tnmy re msiblity to notify the occupant
n,
the anuomems II must lw me laCenireme of Ocvuiaruy.
ELE(-TRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
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0
SPECIAL CIRCUIT /NUSC.
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PERMIT ISSUANCE,
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODFIJREPAIR ❑ DEMOLITION
❑ OTHER
POWER
SWIMMING POOL ELECTRIC
SWIMMING POO
OUTLIiIti - S ITCHES-FIX"TURES
N
CONSTRUCTION TAX
/
SPECIAL CIRCUIT /NUSC.
SEISMCFEE
PERMIT ISSUANCE,
TEMP. MEIERO T
R
NE!W BLDG/ADDITION ❑DEMOLITION
❑TENANT OF OD
IMPROVEMENT /•
❑OTHF,R
POWER
SWIMMING POOL ELECTRIC
SWIMMING POO
OUTLIiIti - S ITCHES-FIX"TURES
N
CONSTRUCTION TAX
/
NEW RPSID LELECI'R SQ FI.
HEATING UNIT RO 100.000 B'IU)
(ASO.. FF. FLOOR AREA
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If TOTAL
PLUMBING PERMI FEE✓{
PERMIT ISS CH
ALTER- ANT-WATER(EA)
VALUATION
STORIESTYPE
/
CONSTRUCTION
\
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BACK 11 -OW PROP: ICL
DRAINS - FL ,R ,AREA. OND.
FIXTURES -PER TRA
GAS- EA. SYSTEM I INC. 40 S
C. GROUP
APN II
/ - /,-O2
GAS - PA. SYSTEM -OVER 4 (11A)
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE'IBAP
PLANCIIF,CK FEB
ENERGY FEE
12 y 135
SEWER - SANITARY - STORM EA, 2a)FL
WATER HEATER WNeNT!ELEC R
GRADING hiili
a
WATER SYSTEM/BEATING
SOILS FEE
WATER SERVICE
IAD
IL'1 Dom RttciptM
NEW RCSIDENTIAh PLMB. ^ SQ�FT.\\ I I
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TOTAL:
MECHANICAL VMFF FEE
SEISMCFEE
PERMIT ISSUANCE,
±REE s LC P131i
PLUMBING HE
ALTAR OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CIM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,M) CPM)
CONSTRUCTION TAX
EXHAUST HOOD (W9DUC'D
HOUSING MH IGATION HE
HEATING UNIT RO 100.000 B'IU)
HEATING UNIT (OVER 100.000 BTU)
PAIR
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VENTILATION FAN(SINGLE RESID)
BOILI!R -COMP (3HP OR 100,00) BTU)
BOILER - COMP(OVER 100.000 BTU)
AIR CONIII'I'IONER
��Jl ISSUANCE DATE
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NEW RESIDENT [Al. MECH. SQ. FT.
TOTAL:I ISSUED BY: I ~�
OFFICE_r.—