S 3978APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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TY OF CUPERTINO BUILDING - ELECTR
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-MECHAI
BUILDING PROJECT IDFY
BUILDING ADDRESS:
.103 0 o 9 ivii?m teealiG
r#j
U 37-250 ❑ Consultant Fm Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION Qly
I hereby anlrm that I nn, licensed under pow Laine o(Chaprer 9 (commencing
pZ with Section 7M))nf Division 3ofthe Businessaud Rofc.sions Crde,and my license is
uFin full furca and effect.
U U License Clans Lic. If
Q, Dare Contractor
ARCIII'111CT5 DECLARA'T'ION
hiet
Z I understand my plans shall he used as public records
E'ad Licensed Pmtx,sional
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OWNER -BUILDER DECLARATION
WQ I Swarthy affirm mat 1 an, exempt from the Contractors Liana law roe the
L U following reason. (Section 7031.5. Businesv and Professions Code: Any city or county
Oh which requires a permit to construct, all,,, imprnvc, demolish, or mIsur any .structure
prim to its issuance, also requires the applicant Tor math pcmtit to fila a ligned nuneaent
} that he is licenced pursuant to the provisionsofthe Contnmrorc License l.uw(Chapters)
Qi (commencing with Section]gM)) of Dooion 3 ofthe Businessand Prolkssions Cual
cC that he is exempt therefrom and the basis for me alleged exemption. Any violation of
^ a Second 9831.5 by any applicant for a perms subjects the applicant m a civil penally of
not more thin live hundred dollars (S.500).
C dO Q I, a, ower, ,I the proycny, nnny umplmyces with wages as their vole coinpensmion.
f�++ will du the work. and the stmemm is not intended or otored for sale (See.]IW4, Booness
3 m and Pr..fescma, Code: The Cuntmcmrs License Law does not apply to an owner of
pmpeny who builds or improves thereon, and who dues such work himself or through
his ow employees, provided that such improvements are not amended m offered for
.ale. IfnM1oxcveu the building or improvement is sold within one year of completion, the
owner -budder will have the burden of Flowing amt he did not build or improve for par,
,,,e .de).
owneras of the property. am exclusively contracting with licensed conatuss to
nn.tmn the project (Sec. 70,14. Boston,, sad Pmfcssinns Code:) The Conduct-, Li -
se Law docs not apply to an owner of property who builds or improves Neaten, and QTY,
who contracts for such projects with a contio dugs) licensed pursuant to me Contractors
Licence Law.
I it. e.entpt under See. . B & P C for this rea.00
owner Dat
I hereby affirm under lethally t�j rjury one of the fallowing ded:vations:
I bavc anA will maintain a Ccni(cam of Consort Ia self -insure fin Workers Compen-
cando. os...ked fur by Section 39(x1 of She Labor Codc, for the performance of the
work our which This permit is Is,.1,L
I have and will maintain Worker's Compcmu(um Insurance, as on,d ed by Scams
37") of the Lmknr Code, fur She pci fnnnance .1 the work for which this permit is issued.
My W'orker's Cumpc tion.. Insurance carrier and Policy number rte
Carrier: Policy No.:
CERTIFICATE OF: EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nil be complencd if am pennit'is axone hundred ilollucc ($ I W)
or less)
1 certify that In me performance of the work Fart which this permit Is issued.I shall
not employ any pecan in any manner ser ac to became subject to the Warkers' Compen-
Z smion law. of Cullf ernm Dae
O Applicant
NOTICIi Tel APPLICANT: IL niter making oris Candia... of Esempdon, you should
F. beams nt,bjcct ria the Worker's Compcmauon provisions of the Luber Cndq you mnM
a'7 forthwith comply with such provisions or this permit shall be deermd revoked.
aQ
CONSTRUCTION LENDING AGENCY
U O I hereby affirm dealthem is a canstmctlon lending agency for the performance of
wP the work for which thispermit is i ... ed(See 3097, Civ. C.)
O U Lender's Name
l'J Lcnds, AUdress,
6. 1 cenlfy that 1 have read this application and state that the above information i.
_ and state law. reldin to
h buildinglagatectcomply with all city county g QTY.
U Z building construction, and hereby autboriu reprcxmatives of this city to euros uponme
aMrve-mentioned property for inspection purtw.ses.
(We) agree to save, indianta y and keep hamdcss me City of Cupcnino a%oius,
liabilities, ludgmcon. cans and exlnn,es which any in any way name ogaina said City
in asequence of the granting of this permit.
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
(/ HAZA )OHS AT.RNLS I ILSCLOSURI?
Will theopplicam or care Id g� cupnnt.mre or M1undlc hvuNouc material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cale, Section 25532(m?
C] Yet F1 No
Will the applicant nt ur (marc building oc upon( In equipnunt or device, which
mit h nuril— air conn minants as defined by the Buy Area Air CattilyMan ansa
District?
❑Yes ❑No
I have read the M1aurdous matudds requirements under Chapter 6.95 of the Cats -
Forms Ili Iib & Safety Gde, Se milia 25505, 25533 and 25534.1 understand that if the
building Jas„ not currently no, eo(smut that it i, on, a,kmibi lit.a nosh lythe sealant
of the fflMoNmcnn which moat la ja primad icsuan'd ,I a Cedilicate at Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 20O AMT'S
OVER 10(d) AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUTTIMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELEC IC
OUTLETS -SWI'' X1
PLUMBING
PERMIT ISSUANCE
ALTER- MAIN &VENT- WATER (EA)
BACK FLAW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, .D.
FIXTURES - PER'MAP
GAS - EA. SYSTEM -I INC.4 NUTLET.
GAS - EA. SYSTEM -OVER 4(FA) \
ell Ai9C/
NIC /CONTROL a
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
� [1❑ ❑
FEE JOB DESCRIPTION
RESIDENTIAL
❑SFDWL KITCHEN REMODEL
11 ADDITION ❑ PLUMBING RE -PIPE
[IMULTI.UNIT ❑STRUCTURAL,
MODIFICATION
C INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING FOOLS
❑/, BATH REM DE EPAIR ❑DES OLITION
,sy OTHERIf
�1
COMMERCIAL:
❑NEW BLDGIADDITION ❑DEMOLITION
[I TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER'
1 . -s
SQ FL
I My FI'. FLOOR AREA SISQ. FT.
SEP 2 7 1991
1 I
FEE n.. !!!
CREASE MAP
SEWER -SANITARY -STORM EA. 2O0 F4.
WATER DEALER WNENTrELECTR
WATER SYS'I EM, TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
IOIAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD DO MECII.
AIR HANDLING UNIT (TO ISOM CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUS''[FOOD (WIDUCr)
HEATING UNIT (TO I M,IXN1 BTU)
HEA1 ING UNIT (OVER 1O0,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP CUP OR 100.000 0.000 BTU)
BOILER - COM P(OVER 10k0O0 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. II'.
I�1
BUILDING DIVISION
FEE SEISh C FEE
ELECTRIC FF.E
P MBING FEE
U
I HOUSING MITIGATIFIN FEE I
PAID
Date
I'OFAL:
ISSUANCE DATE
4- 2g -C� 9
TOTAL: BY:
OFFICE