S 1128APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY QF CUPERTINO BUILDING - SLIM RIC'AL PIT] F NO.
1128
BUIL111NG - UILNUGrv. inRINOGp?,CMpECHANI1AF, 1 1 2 p
DIVISION APPLICA1ION/xRRMI1
IDENIII'ICATIl3N
i`�y`�9 RosCr1�`Ri
IER'S NAME: PHONE:
a i � f_i rc+ PR oP_ csy -
CONTACT':
I hereby affirm that I am licensed under provisions of Chapter 9 (umm�tradag
with Seed.. ]OW) ol'Division 3 of the Business and Prnfc,aims Code, ani my live. is
in full force and
Licen CI s C 5h
Dam TSDI m A—
RCIII'fP.CFS U13CLA '1'10 �{ s
undemaIAAns ry ass used us pub(' retttNsP`V rn� y
Lice des. n 1, O
Oat I am exempt
UECe RAICont'ION
1 hereby .(tine that 1 mu exempt from the Cnntmdors License low for the
following reason. (Section ]malu Business andds-, demolish.
Axle: Any city 1), lcounty
which rcyuircr a permit m construe, alter, improve, demolish nr repair any renurc
pfinr m its issuance, else requitee the -111 Ind for such permit w ice a signed xttemcm
that he is cing wit pursuant m the of Division
of the Contractorsows nd Professions
Law (Chapter 9
(commencingwithhemiSection
an.,ad the
taxi, or
oft he Businessandon.Ay ,latxle)or
Shut he is 31.5 b therefrom and the bosh Ee the allege) exempting Any vloldion of
Semon 7113 n le any applicant Iia o permit subject the applicant m a civil pcwlry of
not Snore than Eve hundred dollars y empl.
LAs owner of the theTooperry,or mY employee.. with wage. as thcir,mle compensation,
anti Jothe work, ander -The rra iinot,Licensorowdofor role(Sec. to all
wnerc1.
of
anti Professions CoJe:'I he Commcmr's License Law dues not apply m an snvncr of
his a who builds E, improves Thereon. and who docs ma, work himself or Through
his own however,
the
pnrvldwf r m such mentis sold w are ern intended m olfered tie
sale rthowever, the building or improvement is sold within one year of completion, ut-
uwner-builJtt will have the burden of proving that he did not build or impose for par
pose of sale.).
0 I, as owner Of the property, all, exclusively contracting with lice ed emu alms to
onswet the project (Sec. 70,t4. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds Or improves thereon, and
who contract for such projecu with a contrudor(s) I evased pursuant Ta the Contrdmatk
License Law.
0 1 am exempt under Sec. .11 & P C for this reason
Owner nate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent m self -insole Int Worker's Compere
eamn, as provided fur by Strube 37M it the Labor Conic, for the pc,fumtd¢c at the
work fur which this permit is issued.
0 1 have end will maintain Wrkds Compensation Bommo ce. as required by Section
3710 of the Fall Code, far the performance of the work for which this permit is issued.
My Worker'., Co usumat1ial boweacE Gaper and Policy nPri Wei 3 11'1 LLL'.
P�.
1T2�Lf A t2�Ml,n
❑ Consultant Fees Paid by Applicant (Initial) _
]TY. ELECTRIC PERMIT
THEME F ISSUANCE:
APPLIANCES - RESIDEN'LIN.
PANELS
UP TO 2n)
AMPS
201-100OAMPS
OVER IIXX AMI S
SIGNS ELECTRICAL
POWER DEVICES I
SWIMMING POOL ELECTRIC
OUTLET S - SWI 'I CHES- FIX TURES
NEW RESIDENTIAL ELECTS SQ FE
COMFFNSATION INSURANCE
('lidssectionneed not be completed ifthe perant Ir for On uhundreddollars(SIIX)
or less.)
1 certify That in the pedormmnce of the work foewM1ich this pmi
es issued, l had
nut employ any persalt In any manner ns us In hccnnm.rnbject ei thhe WorkmsGrmpcm
.it.. laws of Califnmso. Dar,
Applicant I
NOTICE'IT) APPLICANT: If, alter making this Cemlieate of lixempalla, I'm should
tvwmc subject to the Worker's Compensation provident of the Labof Code, you anet
forthwith comply with such previsions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby effort that there is a construction lending agency for the per o res ance of
the work for which This permit is issued (Sec. 3097. Civ. Q)
Lender's Name
I.cnJcrs Addren,
1 certify that I have mad this application and state that the above information is
consist. ( agree to comply with all city and county ordinances and state laws rclaing to QTV.
building n nor ction, and hereby auth ,fin representatives of this city to enter upon the
stave -mentioned pmpcny for inspmrion purposes.
(we).,me to save, indemnify and keep harmless the City of Captain against
liabilities. judgments, costs and expenses which may in any way accrue against said City
n canscgacnce of the granting u1'this permit.
APPI )CANT UNDERSTANAB AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bnildnTg Occupant slofeor h:mdle hazardous m (coal
as dd7ned by the Cupertino Municipal Coda. Chapter 9.12, and The Health and Sal'cty
Cuda Sectinn 25532(u)]
0 vex 0 N
Will The applicant or future building occupant use equipment or devices which
emit haverdous air enmaminanu as defined by The Hay Area Air Quality Management
District?
O Yes ON.
1 have read the hazardous md,mals Ic9urearris under Chapter 6,95 of The Cath
foods Scald, & Safety Cade, Suctions 25511.5, 25533 and 25534, 1 undead nd That if TM1e
building Ams not currently have u Tenant thin IT is my respmsihi lily to notify The occupmn
of The r.Fimments which must he met prior to issuance Of a Cenlrlcae of (kenponcy.
PLUMBING PERMIT
PERMIT ISSUANC Ii
AIR- BRAIN & VENT- WATER (ITA)
I3ACK PLOW PROFFCT. DEVICE
DRAINS -FLOOR, ROOF, AREA. COND,
FIXTURES - PERI RAP
GAS -13A. SYSTEM.I INC. 4 OUTLE I'S
GAS - HA. SYS'1'EbbOVER 4 f13A)
GREASE /I NODS 'I'BE91AL
WAS'T'E INTERCEPTOR
!NEW
SEWERTORM EA. 21X1 FT
'DELECTB
SYSTEMO SEATING
MB, SQ. Ff.
MECHANICAL PERMIT
PERMIT' ISSUANCE
ALTER (IR ADD TO MECIL
AIR HANDLING UNI': FTO Timm CFM)
AIR HANDLING UNIT (OVER 1(1,01X1 CPM)
EXHAUST HOOD(W/DUC'O
HEATING UNIT (TO 100,(00 BTU)
HCATING UNIT (OVER pal,000 BTU)
VENTILATION FAN (SINGI,Ii RF,SID)
BOILER - COMP (311P OR 101,1100 RTU)
BOB.ER -COMP (OVER 1011.000 B'I'U)
AIR CONDITIONER
NEW RESIDEN'IIAL MECH SQ. FI'.
SQ Er. PLO() AIU:A
PAID
FEE
AN7 ANS°®
VALUATION
Ur vurrn IIOU
SroSll:g 'I'YI•Ii CL
OCC. ORUUP
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEF.
GRADING FEE
SOILS FEE
PAID
Dne BcceiptN
TOTAL:
BUILDING FEE
E SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONS' 1' SUCTION TAX
HOUSING MITIGATION FEE
PAID
Omc B"c", w
TOTAL:
ISSUED
ISSUANCE DATE
❑
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
PEE
JOB DESCRIPTION
RESIDENTIAL
O SFDWL ❑ KITCHEN REMODEL.
O ADDITION ❑PLUMBING RE -PIPIT
❑MUTAFUNIT ❑STRUCTURAL.
MODIFICATION
D INT ERIOR ❑CHIMNEY REPAIR
IMPROVEMF:N'F 0SWIMMING POOLS
❑ BA'I'I1 REMODEIIREPAIR 0 DEMOLI'I [ON
❑ OTHER
COMMERCIAL
O NEW BI.DIVADUITION DIiMOLITIUN
OTENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ Er. PLO() AIU:A
PAID
FEE
AN7 ANS°®
VALUATION
Ur vurrn IIOU
SroSll:g 'I'YI•Ii CL
OCC. ORUUP
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEF.
GRADING FEE
SOILS FEE
PAID
Dne BcceiptN
TOTAL:
BUILDING FEE
E SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONS' 1' SUCTION TAX
HOUSING MITIGATION FEE
PAID
Omc B"c", w
TOTAL:
ISSUED
ISSUANCE DATE