B 0342APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY BUILDING - ELECTRICAL II O 3 4 2PLUMBNG-MECHANICAL
UILOF
RTINO
VISION APPLICATION/PERMIT into, arra, nin a"na".1s•Irx ION 50001
O
G)� 7 � (7 �1 ❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that 1 .,it licensed under pmvieians of Chapter 9 (commencing
with Section 7000).1' Division 3.1 he Business and Poifessiays Cade and my license is
in full force and effect
.,A
License Class ry Lic.p
Dan ContmctofX
ARCIII'I'ECI'S DELL ATI
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affmn that I am exempt joint the Contractor's License law for the
following reason. (Section 7031.5, 13tuiness and Professions Cale: Any city or county
which requires a genii rn museum, aper, improve, demolish or repair any stroame
Prior to its issuance. ulsa requires the applicant for such permit to fit a signed umemem
that he is licensed purment m the pmvidons of the Commo nes License Law (Chapter 9
(mmnteneing with Sugion W TNI) of Inskin. 3 orlbu Dusiness and Pmfic,siens Cale) or
that he i, exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to u civil peoulty of
not mare than five hundred dollar ($500).
❑ Las owner of the progeny, or my employees%!in wages as their sole compcnmtion,
will da the work, and arc Mrucwm Is sol intended nr nffemd for male (Sac.7044, Dnxiness
and Professions Calve The Otntrncmr's License Law does not apply to or Owner or
property who builds nr improves thereon, and who Jces such work himself or through
hisemployees, provided that such impmvements are not intended or offered for
sale. If. however, the building or improvement is sold within one year of compin inn, the
wncrbuilder will have the burden of proving that Ile did not hu ild or improve liar pur-
pose ol'suleJ.
I, as owner of the property, am exelmively contracting with licensed contractors to
construct the pMjkm (Sec. 7000. Business and professions Code:) The Coruscmrs Li -
,mo, Law does not apply to an owner of pmpeny who builds m improves thereon, and
who contracts for such projectswith a cmeract r(s) licensed punuanl to the Contractor's
License Law.
❑ 1 um exempt under Sec. . H & P C for this reason
Owner Date
• WORKER'S COMPENSATION DECLARATION
1 hereby ulOrm tinder paadty of perjury one of the following declarations:
❑ Have and wil l maintain a Certificate ofCousenuo self-insurefor Worker's Compen-
sation, as provided for by Section 37M of the LaMar Code, for the performance of the
work for which this p talk is issued.
1 have and will maintain Worker's Compensation Insurance, us required by Section
3900 til the Labor Calc, for the performance of the work for which Ihls #crit is issued.
MyrricWorr.kers nmRen y1 htsymnce ser and Pnllc;t [ I�_ 4
Ce� POIicY Noll
CT:NTIPIC OP COMPENSATION
FROM WORKEkS'
COMCOMPENSATIONSATION INSURANCE
fl'his se tion M,rdn. ba ectopic d if the Permit is foronc hunJml JnIIam (SI(1(q
or less.)
I sonify that in the performance of the work for which this permit is issued.) shall
not employ any Iaenon in any manner so as to become subject to the Workers' Contpen-
O Z satin Laws of Califnmia. Date
z Applicant
NOTICE TO APPLICANT: IL after making this Certificate or Exemption, you should
becoane subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pennll shall be deemed revoked.
Ems" z CONS' 1' RUC' DON LENDI NO AGENCY
G 0 I hereby affirm that here is a construction lending agency for the performance of
F the work for which this permit is issued (Sec. 301 Civ. C.)
O U IamJers Name
W Lender's Address
y 1 certify that I have read this application anti state armthe above infonmution is
h correct. 1 agree to comply with all city and county ordinances unit state laws relating to QTY.
L) z building emennitim,end hereby omhmim reprettnrarivesofihix city la emm upon the
t.
above mentioned property for inspection Purposes
.
(We) agree m save, indemnify and keep harmless the City of Cupanino against
lobi li tics, judgments, costs and expenses
which linty in any way accrue againel sold Ciry
in consequence of the granting of this Permit.
APPLICANTaUNDERSTANDS AND WILL COMPLY WIT({ qLL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building occupant store or handle manamus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cale, Section 25532(a)'
❑rex 1*1
Will the applicant or future building occupant use equipment or devices which
emit hazardous air enntamiumb us deftnM by the Bay Arca Air Qutility Manage
District'(
❑ Yes 6�
1 have read the hazardous materials requirements under Chapter 6q5 of the Cali-
fomia lieu It & $a(sty Coda, Sections 25505, 25533 and 25534. 1 undersmnd that if the
huilding does ocpR IIf a n�nlly have a mown, Net it is my msponsihlThy to notify the o.alar l
,,fine na, tyf which most twymt prior to issuunce'Of. Certificate of Ovcr,mcy
ELECTRICPERMIT '
PERMIT ISSUANCE:
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. MIO HR OR POUT INST
POWER DEVICES
it
SWIMMING POOL ELECTRIC
OUTLET'S -SWITCHES - FI X'I'U R17S
NEW RESIDENTIAL. HLECfR SQ 14.
PLUMBING PERMIT
PERMIT ISSUANCE .r
AUIER - DRAIN & VENT -WATER IRA)
BACK PLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOP, AREA, COND.
FlXTURES - PER TRAP
GAS - ITA. SYSTEM -1 INC.4 OUTL171.9
GASB- EA. SYSTEM.OVER 4 (EA)
GREASIVINDUSTRL WASTE IWF.RCI3PPOR
GREASWI'RAP
SEWER -SANI'T'ARY -STORM EA. 2IXl FT.
WATER REAL Ek W/VFNT/ELECfR
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. PT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING URII1 Cr0
AIR HANDLING U ('17il)VI
HEATING UNIT U #f,WVW
HEATING UNIT (O : 1 III(I,IMN1 R'I'lD
VENTILATION FA4 (.$WGLE RESIDE
BOILER - COMP (3kPflA4NB,9N3B9'tlT'�"'
BOILER - COME(OVIR 100.000 all 11)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL.:
OFFICE
FEE
S
0
JOB DESCRIPTION
RESIDENTIAL,
SJSG� FT
❑SFDWL
❑ KITCHEN REMODEL
[]ADDITION
[I PLUMBING RE -PIPE
❑MULIH-UNIT
❑STRULPURAI.
MODIF[CA'I ]ON
[I INTERIOR
❑ CHIMNEY R17PAIR
IMPROVEMENT
0SWIMMING POOLS
❑ BATH REMODEIIREPAIR ❑DEMOLITION
❑ OTHER
/iTLS
OCC GROUT'
APN
COMMERCIAL:
BUILDING DIVISION FEES _
0NEWBLDG/ADDITION
❑DEMOLITION
❑TENANT -
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
GRADING FEE
%.qf+sf FI,O(IR AREA
7 y
SJSG� FT
FEE
.0
VALUATION
STORIES
'TYPE CONSTRUCTION
OCC GROUT'
APN
BUILDING DIVISION FEES _
PLANCE I17CK FEE
ENERGY 19iE
GRADING FEE
SOILS FEIi
PAID
flare Receipt #
TOTAL
BUILDING EE
FEE
SEISMIC 17EE
ELECT It] 'E
PLUMBING FEE
MECHANICA G
CONSTRUC'T'ION
HOUSING MITIGATION FEE
PAID
Date Receipt#
ITAL.
ISSUANCE DA'EE
ISSUED IIY: r �/