29502APPLICANT TO FILL IN INFORMATION WITHIN RED LINT
CITY OF CUPERTINO
nuu.nw . DIVISION APPLICATION/PERMIT
CONTACT:
1 hereby infirm that l am licensed loiter pr ns of Chapter J lutmmmucing
I❑0C with Section 700[hnf Division 3 dere Business and P s,lanrs Calc,andmy heemel,
F W In lot) force trod fectY
4� Dain mr
F+�y
ARCHITECTTSDE
'S DECLARATION
JuodervmnJ my plans shall be used as public records
Licensed Professional
• USE BALL POINT PEN ONLY
BUILDING - ELECTRICAL
PLUMBING - MECIIANICAL
BUILDING PROJECT IDHNTUT CATION
ONTRAC1T1OR'S NAh,E: A j� NCO/: �
DORFSS
oF('nlAtl e� „� a
❑ Consultant Fees Paid by Applicant (Initial)
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENT AL
PANELS
UP TO 200 AMPS
0Y2 OWNER -BUILDER DECIARATION
a 1 herby uffnn he, I ren exempt from the Convector's License Law for the
XS 0 d U following reason. (Section 7031.5. Business and Professions Cale: Any city or county
+l LL which se tuime a permit to comtmct, alter, improve, demolish, or repair any strunurc
JJ prior to its issuance. also acquires the applicant for such permit o Ne a signed statement
} thin he is licensed pursuant to the provisions of the Committees License Law (Chapter 9
00C
(maintaining with Section7") of Division 3. tons Business end Pmfe ions Calls)
S nr
mthat he is esempt therefrom and the basis for Ne alleged exemption. Any violation of
NSection 7031.5 by any upplieent for a permit subjects the applicant 1. a civil perulty of
t mine than rise hundred dollars ($500).
x�Q ❑ 1, as owner of the progeny, or my employees with wages as their sole compensation,
will d.mv work, and dw, fracture is an, intended.,offered for ole (Site 7144. Business
g3 and Professions Code 'I he Convector's License Law does not apply mire owner of
property who builds or iinpmvcs thereon, tad who ones such wok himself or [hrongh
his own nnployecs, provided that such improvemcnln are not intended or o0cred Iia
sole. If, however, the building s Improvament is sold within one ymr.fannpletl.n, the
owner -builder of 11 have the burden of paving that he did not build or improve for par.pwlo of eule.).
❑ 1, as owner of the progeny, ren exclusively contracting with licensed mnvuctom to
construct the project (Sm. 70,14, Business and Professions Cotler) Tim Cmi mi Li-
ne Law does not apply to an owner of property who builds or improves ILemon, unit QTY,
who connects for such projects with a commemr(s) licensed pursuant to ilia Commences
Lice se Law.
1 an exempt under Sec. , B & P C for this mason
Owner Da¢
WORKER'S COMPENSATION DECIARATION
I hereby affirm under Penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenifcam ofComenuo self-iesum for Worker's Compen-
sation, as provided for by Section 37M of Ne Labor Cole, he the perfnnnance of the
Kw rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3] plhe Labor Coda, far the pvrimaanee fthe work far which this permit is issued
My Wor fs Ct n xa'nnl urn c Per and Pnlicyn
Carrion Policy Nn.:
CIER PICA'TE OF EXE 'ION FROM WORKI]2S'
COMPENSAT NINSURANCE
(Thisseelionnmdnotbec.mple if the permit is fir nna hundred dnllurs($11X8
orlesi)
I mnify that in the performance ofvhe work for which this Perini[ is issued, l shall
nol employ wry petsm in any man so tbject m the W ..mrsCompere
0 Zs bon t Low CoI fate
fn D
z O as um l lu,se 1.1.jL -
V)
NOTICE TO APPLICANT Nafer making this Certificate of Exemption, you should
a; become subject to the Workels Compensation provisions of the Labor Code, you must
W forthwith comply with such provisions or this permit shall be, deemed n,voked,
CONSTRUCTION LENDING AGENCY
Q work
by which
auffirm hthis euM1en, iso issued
3097. ding agency funhe perfomtnnce of
W f—' she work for which this permit is iswed (Sec. 309]. Civ. CJ
,0 U Lender, Nanta
W Lenders Addresamity t that I have mad this application and atom the the nM1nv< information is
.w V) correct. l agree at comply with all city and county ordinances and state laws minting to QTY,
U P, building construction. and hereby authorize representatives oflhis city mentcruponthe
move-mentiomd property for inspection purposes,
(We) agme in save, indemnify and keep hannles, the payer Cupertino aguinat
liabilities, judgmans, ass., aad expenses which may In..y way uceru. uguirel said City
in consequence of the gnmting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Is
S URCE REGULATI�OCCS.
i\am 9e
SignalnrcofApplirVComrea.r - Data
ZARDOUS MATERIALS DISCLOSURE
Will the appiicam or human, building occupant store or handle hazardous material
as defined by the Cupenino Municipal Cade, Chapter 9. 12. and the Health and Safety
Code, Section 25532(,)^ (�J
El Ya, V
W II the applicant or future building occupant use equipment or device, which
emit Inza d us air enumerators as defined by the Bay Arca Air Quality Management
ITsdetl
❑ Yes Ykb
I have read the hazardous materials requirements under Chain,, 6q5 of the Cali.
Tn on Hudvh & Safcvy Code, Sections 25505, 25533 and 25534. 1 understand that if the
building dies not cutrcndy have a tenant, that it is my reslamsibi lity to only the sampan[
(r("a cmc mmenas Vvbitch mastbe met prior m issuance of it CeniMam if Ofeequncy.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — S W ITCI IES — FI XT
29502
%ZK,q$
BUILDING PERMIT INFO
eo eV ",E,---], w�
JOB DESCRIPTION _
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
[]ADDITION .
EJ PLUMBING R&PIPE
❑MULTIUNIT
❑STRUCTURAL
PERMIT ISSUANCE
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
STORIES
❑ BATH REMODEVRF.PAIR ❑DEMOLITION
❑OTHER
jr
GAS— EA. SYSTEM. I INCA OUTLETS
DEC GROUP
1)�
COMMERCIAL,
❑ NEW BLDGIADDITION
0DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
'
❑ OTHER
SEWER—SANITARY— STORM HA. 21X1 PP.
ENERGY.FEE
NEW RESIDENTIAL BLBC'1' SQ IT.
TOTAL:
six 17
`
SQ. FT h1.00N AREA
S/SQ. Ff.
IO
PLUMBING PER FEE
PERMIT ISSUANCE
ALTER—DRAIN & VENT— WATER IRA)
VALUATION
BACK FLOW PROTECT DEVICE r
DRAINS— FLUOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES — PER TRAP
GAS— EA. SYSTEM. I INCA OUTLETS
DEC GROUP
APN
GAS — EA. SYSTEM -OV IiR 4 IiA)'
GREASFIINDUSTRI. WASTH INTERCEPTOR
BUILDING DIVISION PEfiS
GRFASETRAP
PLANCHGCK PEIi
'
SEWER—SANITARY— STORM HA. 21X1 PP.
ENERGY.FEE
WATER HEATER WNENTIELECTR
GRADING FET?
WATER SYSTENIGREATING '
SOILS FEE
VENTILATION FAN (SINGLE REST/
WATER SERVICE
PAID
Dam Receipt#
NEW RESIDENTIAL PLMIU SQ. I.T.
TOTAL:
six 17
`
BUILDING FEF.
MECHANICAL PERMIT
PERMIT ISSUANCE
FEE
FEB
)
�LGCfRIC PCLP
ALTER OR'ADD TO MECO.
VI.VSHMSG FEE
AIR HANDLING UNIT ITO l(Mul) CFM)
UI v
MECHANICAL. FEB
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
EXHAUST HOOD I W/DUCT')
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.00) BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
VENTILATION FAN (SINGLE REST/
Dam Receipt#
BOILER — COMP (3HP OR 160'" BTU)
T'OTA
BOILER—COMP (OVER 100.800 BTU)
AIR CONDITIONER
ISSUANCE DAT/p
/--y <e �iD �/
ISSUEDBY. !/ng ( `!
NEW RESIDENTIAL MECO. - SQ.IT.
1'O1 1.:
OFFICE