30603APPLICANTTO FILL IN
BUILDING DIVISION APPLICATION/PERMIT
C
CONTACT:
.t
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 ufthe Business and Professions Code, and my license is
in full force and effect.
License Class Limp
ARCHITECTS DECLARATION
I undersand try plans shall M used ns public records
- USE SALL POINT PEN ONLY
BUILDING -ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECT IDFNTIFICATU
7er=v rido .
O RACFOR'SryAp4 E: LI
l evin rlunfer J,saar
,DDRESS:
❑ Consultant Fees Paid by Applicant (Initial)
ITY EI.ECIRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200 AMPS
•'�j OWNER -BUILDER DECLARATION
6 I hereby affirm and 1 am exempt from the Contractor's License Law far the
d U following reason. (Section 7031.5, Business and Professions Cody. Any city or county
O y~a which requires a Porous to construct. alter, improve• demolish, or repair any structure
yJ prior to its issuance, also requires are applicant(orxuch Permit o file a signed statement
�. that he is licensed pursuanuo Ne provisions of the Commences License Low (Chapter 9
G� (commencing with Section 7")of Division 3 of the Business and Professions Cede) ar
c oL that he is exempt therefrom and the basis for the alleged exemption. Any violation of
y
Section 7111 IS by any applicant far a permit mhjects the applicant to a civil penalty of
>>>>> ynot more than five hundred dollars ($500).
6Q D 1, us owhirof the property, otoy employees w hh wages as their sole compensation,
will do the work, and the stmeom is not Intended or offered for sale (Sec. 7044, Ilusiness
3 and Professions Cede: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work homelier through
his own employees, provided that such improvements are not intended or offered for
sale, If, however, the building or improvement is sold within one year ofcompletion, the
owner -builder will have lie burden of proving that he did set build m improve for pur-
pnse of saleJ.
❑ h m owner of the Perin , am exclusively convecting with licensed commcmn to
eamtmet the Parolee] (Sec. 70W, Business and Professions Code:) The Convenor's 1.i-
ceme Law does nm npPIY m an owner of progeny who builds or imprnva thereon. and QTry
who contracts for such projects with o COmonarons) licensed pursuant m the Cantmnors
License Law.
❑ lunt exert under Sec. -, a & P C{nr this ninon
ncr
WORKERS
w KER'S COMPCNSAi'ION DECLARATION
1 hereby affirm under Penalty mf perjury ane of the following declxrmiam:
❑1hav and will for by eCenificam of Con sent to self -insure far Worker's Ce of the
salon, m provided for by Section 3]110 of the Labor Code, for no perfommnce of the
coot far which this permit is issued.
❑ 1 have and will maintain he Performance
er orante aftheCompensation Insurance, az requited by issued.
My of thelairs Codgfor theeurance mnceofthework for which Nispermit is issued.
C. Worker's Compensation Insurance carrier and Policy number aro
Comer. Policy FROM
CERTIFICA'T'EOP COMPENSATION
FROM WORKERS'
COMPENSATION INSURANCE
(This section need not heenmplmoJ it the] perndt Is for one hundred Anllurs ($ IfAB
n Icsx.)
I eerily that In the performance ofthe work for which this permit is issued, I shall
not employ any person in any manner to as to become subject to the Workers' Compen-
0 z sauon Laws of California. Date
Z Applicant
tiNOTICE FO APPLICANT. If. after making this Certificate of Esemption• you should
abecome subject to the Worker's Compensation provisions of Ne Irabso Cale, you must
H.lQfoMwiN comply with such provisions or this permit shall be deemed revoked.
z CONSTR UC ION LENDING AGENCY
V O I hereby affirm that hem is a conslmetion lending agency for the performance of
kL the work for which this Permit is issued (Sec. 3097, Civ. C.)
Q U Lender's Name
W Lender's Address
y I certify that I have read this application and state that the above infurmminn is
V) correct. l agree to comply with all city and county ordinances and state lawn refuting to QTY_
V z building construction, and hereby acturize represemmivea ofthis city to etnerurynt the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify sad keep harmless the City of Cupertino against
liahilities.judgmrnte, covx and expenses which may in any way seems againn said City
in cmumemo ace of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signuom of ApplimmUCmanutnr i Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or bundle hawNnus material
as defined by the Cupertino Municipal Code, Chapter 912, and the Health and Safety
Gde, Section 25532hol
❑Yes Otho
Will the applicant or future building mcupant use equipment or devices which
emit baznNous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes 7 N
1 have read the hmeafdous materials wauirenents under Chapter 6.95 of the Cal i-
fomia Health & Safety Code, Sections 2,55115, 2,5533 and 25534. 1 undrodund that it the
huithing does not currently have a tenant, that it is my responsibility m notify the uu:cnpnnt
of the ruptimmems which most he met prior ut Issuance of a Cmifiesm of Occupancy.
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- S W ITCEI17S - FIX'rU RES
SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PRO'T'ECT. DEVICE
DRAINS- FLUOR. BOOP, AREA. COND.
FIXTURFL - PER TRAP
GAS- EA. SYSTEM -1 INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
INTERCEPTOR .
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WNENTMLECfR
WATER SYSTFMCPREXnNG
WATERSERVICE
NEW RESIDENTIAL PLMB. SQ. IH'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MI CH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD(W/DUC)
HEATING UNIT (TO IMAX) BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILA'T'ION PAN (SINGLE RPSID)
BOILER - COMP (311P OR 100.000 BTU)
BOILER -COMP (OVER 100,010 BTU)
AIR CONDITIONER
NEW RF,SIDENTIAL'MLCli. SQ, Fr.
OFFICE
JOB DESCRIPTION
30603
NITARY NO,
APPLICATION SUBMITTAL DATL
❑ PLUMBING Rr PIPL
❑MULTI -UNIT
,r- (�
N/C
MODIFICATION
CONTROL#
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEVREPAIR El DEMOLITION
BUILDING PERMIT INFO
BLDG
E5L�ECCT PLUMB MECH
E:1/
_ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING Rr PIPL
❑MULTI -UNIT
❑STRUCTURAL
SOILS FEE
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEVREPAIR El DEMOLITION
❑OTHER
COMMERCIAL:
C1 NEW BLDG/ADDITION
El DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEM17NT
❑ OTHER
FEE /SEP 3 0
]996
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
PEE:SEISMIC FEE
ELECFRICF
PLUMBI ME
HOUSING
PAID
Date Rescipt#
ISSUANCE