B 0150APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO LOMB I G- ELECTMECILRICAI. PERMIT NO. v0 1 5 0
APPLICATION/PERMIT PLUMB co NG-MECHANICAI. .v
ItU11.DING DIVISION mm nswr. vvntcrT mvwnetrn•rin!v Sal
Nunn
7h-49/////�
IMM"
74^ _ 7AG� ❑Consultant Fees Paid By Applicant (Initial)
1 hereby affmn that I an) licensed under provisions of Chapter 9 (commencing
won
with Senion]IXlo)ol DivisinnJof the Nosiness anJ l'mfeasions Code, and mylittnse is
CW O= in full farm and eRce:—ra/ �/ .196/5
Q U w LiccnseC a Gsq�-�b Ccur ac SF Y
H66 Ucen •V%—/ Conon
ARCHITECTS DECLARATION
CW ra I understand my plans shall be used as public oreards
z=o
lot ] Licensed Professional
1] UWNIiR-BUILDER DECLARATION
a 9a I hereby . (Section
on 1 um exempt from the Contractor's License Law far the
3 S fallowing reason. (Sermon ](Il l S, Business and Professions Code: Any city or county
LLO which requires n permit re construct. alter, improve. tfor
sudemolish, or repair any tamnure
poor m its issuance, also requires the the applicant for tach permit m files signed statement
�} thio be is licensed pumuannn the ofprovisions
sion 3 the
eBusinessni Professions
Law (Chapmr9
tYa� lmnmmncingwith Season](anti the bassionr of the Business end Professions Cade) or
O qOq that he is exempt any...n and the basis for the alleged exemption. Any l violation of
Satinn 7031.5 by any applicomforapesmit sobjeas the opplicammacivil Penalty of
.F.i more than five hundred dollars ($500) �O ❑ I, as owner of the pntpcny. car myempioyces with wages us their sole atmpensminn,
will do the work, and hustrectute is not intended or offered for sale (See. 7044. Business
63 and Professions Cade: The Contactors license law does not apply to un owner of
property who builds m improves thereon, ami who docs such work himself in through
his Own employees, provided than such impmvemems are not intended or offered for
sale. IL however, the building or improvement is sold within one year of completion, the
owner -builder will have the Nader Of proving dial he did not build or improve for pur-
pact- of sale.).
I, asr of the property.am exclusively convecting with licensed conaacmr In
amstmm the project (Sec, ]004, Budncss and Professions Cale) The Contvrors Li-
cense Law does not apply to an owner ofproperty wha builds or improves thereon, and QTY.
who contracts for such projects with a contactor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sm. , B & P C for this mason
Owner Date I
WORKER'S COMPENSATION DECLARATION
I hereby aff rn under penalty of perjury one of the following declarations:
I have and will nwannuo a Certificate of ConsentTo self -insure for Woram's Compen-
arinn, as provided an by Section 3700 of the Labor Cade, far the perforrinam al nor
work far which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
37W of the Labor Cade, fnr the performance of the work far which this permit is issued,
My Workers Compensation Insurance cancer and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURA NCE
(ITis se can need nut her completed ifthe permit is for one hundred dollars D I utq
less)
I cenify that in the performance of the work fill which this permit is issued. I shall
nm employ any person ins nm rot me IepJotM1e Workers' Croupier.
,� A 'h Laws oJM% _ 6
Z O nppfeant
NOTICE PLICANT: I,aRer making this Cenificnte of Exemption, you should
h" 'N" becomes teal the Wnrpr Compensation provisions of the Lubar Cale, you muu
l�tl ny
forthwith comply with suchh provisions or this permit shall he Deemed revoke).
CONSTRUCTION LENDING AGIiNCY
U 0 Thereby alFtm thanhcrc isaconswction lending ngeney forthe perfirtnnuuv ml
LL H the work far which this permit is issued (Sec. 3097, Co. C.)
O ULenders Name
Lendds Address
ll 1 cenify that I have read this application and stale thio the above infisrmabnn is
ti h moms. l agree m comply with ell city and mum, nNinantts and state laws miming m QTy,
U%.. building construction, and hereby authodea representatives ofthis city to enter upon the
akne-mentioned propeny for inspecdon pu"ws.
f We) agree to save, indemnify and keep hatha City of Cupcniagainst
IiaM1ilities,judgmenrs, cosy and expenes swhich may
icn an any way accrue againstrsnit City
APPLICANT
NTT of thegrinning this permit.
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Blore or handle hasnrdnux mater:d
its defined by the Cupertino Municipal Code, Chapter 9.12, and the f rauh mod Stacy
Cale, Section 25572(u)'I
E] Yes
Will the applicant or future building m of am use quipment or devices which
:mit harardons air contaminants as defined by the Bay Area Air Quality Management
District]
E] Yes XNo
Ihave thyus mmetiararyircm ^ erChapter h.95ofthe Call.
fmniu Iierm &. oft Cnd• Secllnm 25 05, 25 25574. 1 understand thio If the
huilAialNces urrc veamnanl at it amsihllity mcold y the necupum
met pnm)6-(yfYf cofa
ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 200 AMPS
SIGNS ELFCI'RICAL
SPECIAL CIRCUIT/MISC.
TEMP. MEHiR OR POLE INST. 10,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESI DENTIAL ELECTR SQ ET.
PLUMBING PERMIT
PERMITISSUANCE. 5
ALTER - DRAIN & VENT- WATER (FA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GASB -EA. SYSTEM OVER 4 (EA)
GRFASWINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANI'T'ARY -STORM EA. 200 Pf.
WATER HEATER WNENTMI-ECTR
WATER SYSTEM?RGTING
WATER SERVICE
NEW RESIDENTIN.PLMB. SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE?
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO BLOW CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WIDUCn
ORATING UNIT GO Ilk," BTU)
HFATIN(I IINIT(OVER 100,100 BT'U)ff
VTNTILA'1'ION IAN (SINGLE RESID) P
BOILER- COMP OR BOILER -COMP OR 110,0000
BOILER - COMP (OVER 110,000B'1'U)
AIRCONDI'1'IONER G11) VL v
NEW RESIDENTIAL MECH. SQ, Er.
OFFICE
INFO
FEE
SQ. FT. FLUOR AREA
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING R7.G El
SOILS ME
PAID
Dom
BUILDING FEE
FEF. SEISMIC FEE
ELECTRIC FEE
PLUMBING 171717.
MECHANICAL 111717.
I HOUSING MITIGATION FEE i i
PAID
Date Receipt is
ISSUANCE DATE
(0- / S 7_)Q1
IFXYSIRSlWA
❑ ❑ t ❑
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCH17N REMODEL
OADDITION El PLUMBING RE. -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
El INTERIOR EI CHIMNEY REPAIR
IMPROVEMENT 71SWIMMING POOLS
❑ RATH REMODE /REPA 2 DEM'd I]N
❑ OTHERxz
COMMERCIAL,
❑NEW BLDG/ADDITION C1 DEMOLITION
El TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
1
FEE
SQ. FT. FLUOR AREA
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING R7.G El
SOILS ME
PAID
Dom
BUILDING FEE
FEF. SEISMIC FEE
ELECTRIC FEE
PLUMBING 171717.
MECHANICAL 111717.
I HOUSING MITIGATION FEE i i
PAID
Date Receipt is
ISSUANCE DATE
(0- / S 7_)Q1
IFXYSIRSlWA