30354APPLICANTTO FILL IN INFORMATION WITHIN
BUILDING DIVISION APPLICATIONIPERMIT
70
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QXZ with Section]OBO) of Division 3 of Ne Business and Professional Cole, and my license is
Gly- in full tome and effceL j/
Lice
mea Contractor
[�++ ARCHITECTS DECLARATION
ZO p 1 understand try plans shall he used as public rounds
F¢d Fq �Q5 Licensed Profe"amill
bd2 OWNER -BUILDER DECLARATION
yy�d PDLL YY6C'11 1 hereby offimt that 1 am exempt from the Contractors License Law for the
W 3 IL following reon. (Section 707 L5, Business and Pretensions Code: Any city or county
F = 0.0 �j which tegm a permit m construct. almr, improve demolish, or repair any swam.
y prior to its issuance. also requires the applicant for such pmmit to file a signed statement
<F that he is licensed pursuant to the provisions of the Contraction's License Law (Chapter 9
(commencing with Second ]IKKp of Division ] of the Business and ProfessionsCtnlO ar
that he is exempt therefrom and the basis for the alleged exemption. Any vioLninn of
it 4.Section 70315 by ally applicant for a Permit subjects the applicant m a civil penalty of
41 y nm more man five hundred dollars ($500).
CI, m owner office prupeny, or my employees with wages as their sole compensation,
_ will da Newark, and The
Comisno's License
Law
does not apply oi4, Business
and Professions Code: The C than rs L nd w Lew does not apply ar an owner of
0. 3
property who builds or improves t thereon, end who ntss such work himself or through
his own empinyeex, pmlding that such improvements arc not intended or offered for
owner -bower will hbuildingorimprovement issold withi none yewoimprovetfor the
owner -builder will have the burden of proving that he did not build or improve far pury
missile.).
0 1, as owner of the Senpeny, aim exclusively contracting with dTheComwdea i-
construct the p.ject (Sec. ]010, Business and Professions Code:) The Convenors who
cit.n Li -
,do.
wlaw nm apply M an owner of property who builds or improves Nret
em, oad
who contracts for such pmjcan with a cunwcmrtq licensed putsuam to the Commcmh
) Lew.
CIam exempt under Sec. ,B&PCfor this lemon
caner following
WORKER'S COMPENSATION DECLARATION
I hereby short under penalty teperjuryoneo self -insure
for Worker's
Co
❑ I have pnd rovide for by
a Cion 37 M of Consent eLabor Code, for the
a (form n Ce of th
.alien, , provided for by Ssnion 3]00 of the Lubin Code, for Ne perfurmance of Nc
work for which this permit is issued.
❑ I have and willmeimor Workers Compofthe n work
which
h required by Section
J](KI o(Ne LeMrCale, for the performarttt of the work for which Nis permit is issued.
USE BALL POINT PEN ONLY
BUILDING. ELECTRICAL
❑ Consultant Faces Paid by Applicant (Initial)
ZTY. ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES—RESIDENTIAL
\PANELS
IJI' O4WAMPS
/ Comer: Policy No.:
CERTI171CATLI OF EXEMPT ION FROMWOR ERS'
COMPENSATION INSURANCE
(This section need nm be completed it the Norat is fmone hundred dollars ($100)
m less.)
1 certify Nm in the performance ofthe work for which this permit is issued,, shall
no employ any person in any manner w as to become subject to the Workers Ci mpen-
,� Nation Laws of California. Date
Applicam
y NOTICE TO APPLICANT: If. car, malting this Ceni fare or Exemption, you should
abecome subject to the Workcr'a Compensation to, isions of the Luther Code, you most
W forthwith comply with such prnski..... this permit Nhull lw deemed revoked.
Z CONSTRUCTION LENDING AGENCY
C.) 0 I hereby affirm thus there is a construction lending agency for the performance of
W. f" the work for which Nis permit is issued (Sec. 3097, Civ. C.)
0 Lenders Name
Lenders Address
1 certify that 1 have mad this application and state that the above information is
Tall collect I agree to comply with all city and county ordinances and state laws relating to QTY.
V 4 building constructed, and hereby..,hall. repremntativesnlNin city In enter alum the
above-mentioned propcny, for inspection purposes,
(We) agree to save, indemnify and keep harmless the City of Cupenino against
liahililies,judgmems, cans and expenses which may in any way came against said City
in co mempu num of the grmting of this Permit.
APPLICCAXI UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532fa)?
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air comaminnms as defined by the Bay Area Air Quality Management
District? .
❑Yes ONo
I have read she hazardous materials requirements under Chapter 6.95 of the Cali.
forms Health & Safay CoJc, Sections 25505. 25533 and 25534. 1 understand that if Ne
building does not currently have a tenant Nat it is my responsibility M notify the comprm
of the reap rements which must be mer poor to issuance of r Cermi com of Occupancy.
Owner or authorized agent Did.
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. KHMER OR POLE INST.
I'OWI?II DEVICES
SWIMMING POOL ELECTRIC
OUTI.EfS — SWITCHES — FIX'1 V RFS
NEW RESIDENTIAL ELECTR SQ FT.
PLUMBING P13RMIT
PERMITISSUANCE
ALTER— DRAIN & VENT— WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR. ROOK, AREA, COND.
FIX FURLS —PER TRAP
GAS— EA. SYSTEM -I INC. 4 OUTLETS
GAS — IM. SYSTEM-OVER4(fill)
GREAS EIINDUSTRL WAST F. I NTIIRCEP GIR
GREASETRAP
SEWER — SANITARY— STORM HA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. ET.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTRR OR ADD TO MECl/.
AIR HANDLING UNIT (TO I0,00 CPM)
AIR HANDLING UNIT (OVER 10,000 CEM)
E.XIIAUS'r 1IOOD (W/DUCT)
11EA'1'INO UNIT(TO 100,001 BTU) 1
HEATING IINIT(OVER IOL" BTU)
VENTILATION FAN (SINGLE RE.SID)
ROILER —COMP (3HP OR I(AI,f)(10 BTU)
BOILER — COMP (OVER 101,010 BTU)
AIR CONDITIONER
NEW RESIDE- AL MECH. SQ. FT.
OFFICE
9
R
se Fv-
FEE ED JOBODESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION OPLUMBING RE -PIPE
❑MULTI.UNH' ❑STRUCTURAL
MODIFICATION
^� ❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑BATH REMOD UREPAIR ❑DEMOLITIO
[]OTHER
NEWBLDG/ADDITION! ❑DEMOLITION
❑TENANT ❑FOODSERVICE
. IMPROVEMENT
❑ OTHER
SQ. FE FLOOR
OOR AREA $/SQ. Er.
1996
STORIES
FEE
STORIES 'FYIT CON!
GCC. GROUP Al
BUILDING DIVISION FL'4S
PLANCHECKFEE
ENERGY IEE
GRADING HE
SOILS HE
PAID
Dme Receipt p
TOTAL:
BUILDING F'li
FEE. SEISMIC FP .
1 ELECTRI FF.P.
PLUMBIN FH
MECHANICA FEE
CONSTRUCT[:rAX
HOUSING MITI r TION FEE
I
PAID
Dare Receip N
Tolosa: