S 0575TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I hereby affirm that I nm licensed under provisions of Chapter 9
with Sstion]IXX)1 of UivisionJof the l{usinessa d hnfcssinns tJc�an
in full face and 4J V(
License ClmsLic.If
❑ Consultant Fees Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
ZO t -NZ
o,
1 or
l understand my pians Ball be used as publiclyfON'
Ah1P5�LicenwJ
no,_
LLF
t.prior
F G
$�+
1� a
Prnfessinnal
DECLARATION
hereby e.0 ono Thal 1 am w,rapl from the Contactor, License Law far thehillowin6reason, (Section ]11)15, Nosinessand Professions Cole Airy ciry or countyECTRICAL.W
which requires a permil m combat, nher, improve, demolish.or mod, any arcnre
to its issuanceulsnrequires me.pplirumfnr such permil to file. siynedslatemnt
p... a)nsof theCombecons License Law lChapmr9mmracrej.wish Sec000 700(hof Division 3ofma Bunincss and Professions Code) orETER
be is unapt Ihercfrnm1md the hvsis frIho nlle,ed exemption. Any violaion illSection 9(1315 by any applicant Farm permit subjects the applicat lo. civil penally ofEVICES
marinate then five hundred dollars (S510).
Fl1, us owner of the property,or by employees wilh wages ns their snlc cnmpennntlnu,
wJl do rho work, nnJ the svuclure is nal irnunJcA nr nl'I'crnl hasnlu (Sea 7044,9usinesx
and Profession, Cade: The Counselor', License Lnw lines ern "'uy Io un owner of
properly who huilds nr improves Ihernm, and who dares such work hinsxelf or Ihrmgh
1 1 1 offcmd for
MPSOWNI:R-BUILDER
CAMPSI
=AMPS
CIRCUITdHSC.tamheahcenseJpurmer,a,c
OR ('OLE INS'T.het
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES- FIXTURES
NEW RESIDENTIAL HLPLTR SQ FT.
his own entplayess, provided taw such unpu.vcnsurvs me nal n enru
sale. if, however, the building or Impno,e ma bvJd within enc yearofcomplction,Iho
ncomilder will have the bnrdar of proving mat he did sun bolld or bnpmve fill Pal
pov, rmic.).
1, as owner of the prnpcny, ani uclesively unnhucling with licensed emtrucnns to
n..m ct she project (See. 71314, business all PreleWb is Code:) Thu Commeters Li-
cense Law Anes not apply as an owner of property who builds or improves thereon, and QTY,
who contracts for such projects with v contractors) licensed protest to the Coulaca l
License Lies.
❑ I am esemptunoun Sec. ,H& I' C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury, one of the following declarations:
I have sod will maintain a Certificate ofConwm or self-insum for workers Compen-
sation, a provided for by Section 37M of Be "her Cole, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37M of the Labor Cole, far the pubbermvnce of the work for which this peman is issued.
My Wolds Compensation Entrance carrier and Policy number arc:
Carrier, Policy No.:
CF,RTIFICA Or OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this ration used nen he completed Hthe permit is fornne hundred dolls, IS Ion
or less.)
I certify mat in the perfnnnanee n(,dw wrack whi fLhiz pupnit is issued, l sol
na employ4AC�A,
in any manner roll. e,auh'.l/y}to th/(Workers Com
O Z -tion Lawz ApplicaNOTICETthis Cenificvle of Exemption, you should
become'aWorker', Cornpensatinn provisions of the L.hnr Code, you must
forthwith comply with such provisions or this porred shall he deemed revoked.
]z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a con.grctinn lending agency tonne perlormnnce of
W O the work far which this permil is issued( Sce. 31197. Civ. C.)
Q ULeader's Naas
Di Lenders Addreoi
�.I F 1 codify that I have rand this application and store Amt the above iNnnnudnn is
fir N con cat. I agree in coompdy with all city and enunly ordinances and alai, laws redwing In QTY.
(,% building umxlmmion, and hereby nnthorim rcprcselmivu nr lads city In enter nine. tire
anovo-nmminnel property lin i."w'iion.... pter"
(We) agree or save, indcnmdy and keep hail ble" Ian City e.1'Cimertiun againsl
liabilities, judgments, costs and expenses which any In any way sccmu... first said City
in consequence of the granting of this permil.
APPLICANT UNDERSTANDS"D WELL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
dl me.pplicant or future building aseup.nt store or handle hamNous material
fed by the Cupertino Mmuln w Cale. Chapter 9.12, and the Henhh and Safety
C .Section 2553$0)1
❑Yes r7 No
Will the applicant or future building accupunt use equipment or devices which
hazardous air contaminants as defined by the Bay Amu Air Quality Management
ctu
❑Yes ❑No
I have read she huvadnus materials m pencomnts under Chapter 6.95 of the Cali.
folia Health & Safety Carle, Sections 255115, 25533 ami 25534. I un lcrvand that if she
building docs not currently have s tenant. that it is my reipturc bilily to notify the occupant
of she mommrents which must be met prior to issuance of a Cenificam of Occupancy.
Owner or aushanzal agent Data
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER IEA
BACK FLOW PROTECT. DE
DRAINS- FLOOR. ROOF, AREA, ND
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC.4 OUTLETS
GAS- F.A. SYSTEM OVER 41EA)
GRE•ASEoNDUML WASTE. IN E, RCI-'.]'[ OR
GRF.ASETRAP
SEWER - SANITARY - STORM FA. 201 FT.
WATER HEATER WNENTIF.LECIR
WATER SYSTEMOItEA'1'ING
WATER SERVICE
NEW RESIDEM']AL PLMB. SQ. PI'.
PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IQOW CPM)
AIR HANDLING UNIT (OVER 10,101) CPM)
EXHAUST HOOD(WIDUCT)
HEATING UNIT (TO 100,01X0 BTU)
HEATING UNIT (OVER Baron) BTU)
VENTILATION FAN (SINGLE MEMO)
BOILER -COMP (3HP OR 1 W,BOO BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, IT.
OFFICE
0575
BUILDING PERMIT INFO
[it DO E3I F.CT PLUMB SIFC)i
❑ ❑ ❑ /If eEyl{`
PEE JOB DESCRIPTION
RESIDENTIAL
❑SPDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULFLUNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR (3 CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BAI'II RIiMODEIJRI?PAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL
❑N13W BLDGIADDI'FION ❑DEMOLITION
O1ENANT ❑ FOOD SERVICE
IMPROVEMENT'
❑ 01'1IFR t
SQ. 171. FLOOR AREA SISQ.FL
PAID
FEE. AUG 18 RECD
I BUILDING DIVISION FEES
PLANCHECK hili
ENERGY 113E
GRADING FIBI
SOILS FEE
PAID
[)am -__T_
[)am
TOTAL:
- BUILDING IEh
Plili SIi19MICFFIi
Iil.l7C'I'141C FIFE
PLUMBING FEE
MECHANICAL. ITH
CONS HRUC PION TAX
HOUSING MITIGATION PEE
�rnlD
Dae Receipt M
TOTAL:
DATE