29946APPLICANTTO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAI. PERMITNO. /A /N
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING' MECHANICAL L `V/ Y6
�-r BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: I SANITARY NO. I APPLICATION SUBMITTAL DATE
Ra6nrf L:n �AJJSOs8PWM31�(r4C/s/S6
CONTACT
❑ Consultant Fees Paid by Applicant (Initial)
W'a Z I hereby onion Nat I am licensed under provisions of Chapter 9 (commencing
with Section 7") of Division l of the Business and Professions Code, and my license is
F, 0 C in full force and effect.
Lick.. Class Lie. p
NC Dat. Connucmr
F -,y A CHITECT'S DEC1.A,9]'ION
O2understand y E - cords
r4t: Ida a1
z , OWNER -BUILDER DECLARATION
st 1 hereby affirm that 1 am exempt from m
the Commnrs License Law fertile
3 a U following reason. (Section 711 L5, 511mols and Professions Cade: Any city or county
Owhich requires a permit to construct, alter, improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
d� that he is licensul p.Iran' to "to pmvrsinmof the Cmmimmr's License Luw lChaptar9
(commencing with Section 7000)mfDivision Statue Harness and Prnl'esslons Code).,
that he is exempt therefrom and the basis for the alleged exemption Any violation of
LLX1 4• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Fz>' not more man five hundred dollars($5W).
S p ❑ 1, as owner of the property, army employees with wages as their sole compensation,
I -•y will dote work, and the stmeture is not intended numbered for sale (Sec.?014, Business
L 6C
an and Professions Cosh: The Commcmes License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, pmvided shot such improvnnents are not intended ar offered for
sale. if, however, the building or improvement is sold within one year of completion, the
ter -builder will have the burden of proving that he did nm build or improve for pur-
pose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
conswct me project (Sec. 70CL Business and Professions CWe:) The Conracmes Li -
se Law does not apply to an owner of property who builds or improves metered, and QTY,
who umtivcts far such projects with a contumacious) licensed pursuant to the Contractor's
License law.
❑ Iamexemptunder Sec �B&PCforlhisreason
OwnerDue
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
] Ihave and will maintain a Certificate nfCmoenuo self-imurefar Walker's Compen-
tanion, as provided for by Section 37W of the LUNsr Cale, for the perfonmance of me
work for which this permit is issued.
❑ 1 have and will maintain Worker's Cmnpensadon Insurance, as required by Section
3700 of the Labor Cale, lir the perfornence of the work for which this permit is issued.
My Worker's C�Bonirksum�n�ce� carrier aIy1 Policy numbers
Carser.Nr•'/l /�//rjrey No.: Ir"�1 nAriLS
CERTIITCA'f v OF�FiI(EM'11DON FROM WORKERS' yvI/ g
COMPENSATION INSURANCE
(This section need not Im completed ifthe Permit is forms, hundred dollars (SIDE
or less.)
I certify that in the performance of the wink for which this permit is Issued, I shall'
not employ any person in any mon ter so m In become subject m the Workers' Compen-
O x. sabot laws of California. Date
Ze Applicant
y NOTICE TO APPLICANT. If. after making this Certificate of Exemption. you should
a , become subject to the Workers Compensation provisions of the Indoor Code, you must
forthwith comply with such previsions or this permit And be deemed mvmked.
%r CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
'� the work for which this permit is issued (Sm. 3097, Civ. CJ
Q L% Lender's Name
Leader's Address s
y L certify that 1 have read this application and state and the above information is
Q1 correct. I agree to comply with all city and county ordinances and state laws relating to QTY,
( building consauction, and hereby authorize representatives of this city to enter upon are
above-mentioned property for inspection Pop -
Oksm agree to save, indemnify and keap hdmdess the City of Cupanit against
Iishiludic, judgments, costs ad expenses which cry in any way accrue against sold City
in consequence of the granting of this permit
APPLICAt J'"1dCQER.T NDS Ati"VILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicanterr furore building octet, I stnfecar handle hinarba material
.s defined by the Cupertino Municipal Code, Chapter 9.12, and the Heahh and Safety
Code. Section 25532(.)?
El yes FNo
Will he applicant or future building occupant use equipment car devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management
IOtsain?
O Yes No s >•
1 have read the hazardous materials requirements under Chapter 6,95 of the Cali-
famia Health & Safety Cale, Stations 25505, 25533 and 23534.1 understand that if are
Wilding does not currently have a tenant mat it is my responsibility to notify me occupant
of me requirements which mon W met prior to marance of a Ceniromm of Occupancy,
Owner of authorized agent Dale
ELECTRIC PERMIT I FEE
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANTS
UPT0300AMPS
SIGNS ELECTRICAI.
SPf:C1AL CIRCUIUMISC.
T EMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL HLECTR . SQ In'.
PLUMBING PERMIT
PERMIT ISSUANCE dl�
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
BRAINS- FLOOR. ROOF, AREA, GOND.
FIXI URES - PER TRA 1'
GAS- EA. SYSTEM. I INC. 4 OUTLETS
GAS - F.A. SYSTEM OVER 4 (EA)
GREASEANDUSTRI, WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA 200 IT,
WATER HEATERWNENT/ELECTR
WATER SYSTENITREATING
WATER SERVICE
Pt.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT LTO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD(W/DUCT)
HIzNI'ING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 1110,000 BIT)
VENTILATION PAN (SINGLE RFSID)
BOILER-COMP(3HPOR 100,000ETU)
BOILER -COMP (OVER 100,00s) BTU)
AIR CONDITIONER '
NEW RESIDENTIAL MECH. SQ, ET,
OFFICE
TOTAL.
FE]
15 q G
BUILDING PERMIT INFO
BLDG ELECT PLUMB, MECH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL,
❑SMWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBINGRE-PIPE
❑MULTI -UNIT
❑STRUCTURAL.ATI
MODIFICON
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEDR�F?AIR 11DEMO
❑ OTHER -it I
V 111 I
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
Q. FT. FLOOR AREA
FEE
*01
cop c„, 81996
STORIES
$/SQ. Ff.
I BUILDING DIVISION FENS I
PLANCHECK PEE
ENERGY FEE
GRADING FEE ,
SOILS FEE
PAID Data fteccvp
TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC IEE
PLUMBING IEE ,
MECHANICAL FEII
CONSTRUCTION TAX
_.. HOUSING MITIGATIO'.
PAID
Data Receipt
O
1
ISSUANCE DATE
ISSUED BY: