S 0614APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING, ELECTRICAL PERMIT NO.
BUI 14 )INGDIVISION APPLICATIONIPERMIT PLUMBING .MBCHANICM' S 136 4
I)UILDIN(: PROJECF IDEN'IIFICATIDN
2:fDUM
❑ Consultant Fees Paid by Applicant (Initial)
AlIg%QIv/ f� —N''AMMN IJIEL
LICENSED CONURAMORS DECLARATION
1 herby affirm thud 1 am live reed under, pm r,inm of Chaper 9 (commencing
with Scroun 00X113) of Division 3 of the Raciness and Professions Code, snit my licence is
in full fort[ sad eff
License ` Lic.p
Dade Cmamuw
ARCHI'I 17CT'S DI?CLA A'1'ION
1 andersand my plans shall be weed as puM1lic records
Licensed Prnfessimad '
OWNER- BUILDER DF.CLARA'I'ION
1 hereby athrm that I am exempt from the Contraram's License Law for the
following reason, (Section 7031.5, Business and Professions Cale: Any city or county
which requires a permit In construct, almn ingmnvc, dcmdish, or repair my.strmmre
prier to its issuance, star) requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Code) or
thin he is cscntpl Iher9 tom and the basis for the alleged cxemTlimn. Any suddion of
Section 70115 by any applicant for a peier, stibiens the applicant m a civil penally of
not mare than five hundred dollars (55 s
I, as owner of the property, or my cm byes, with wages as their sole compensation,
willdo Ihowork.andthexwcau Ix amtimenAi} 1nrn0eed for sale (Sec. 9044, Busines
and Professions CM.. Ha Contraclurs License Luw Jnes not apply m an owner of
pmneny who builds or improves thereon. J who does such work himself or brought
his own employees, provided that such improvements am not intended nr offered for
sale, If. howcvvr the hu dding or Improvement is cold with In one year of complctian, the
wntt-builder will have the burden of Tousle, that he did not build or improve to, pur-
no. of sule.).
D I, as owner of the nunnery, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code ) Em Contractor's Li-
cerise Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with s contranor(s) licensed pursuant n the Contractor's
License Luw.
❑ I am exempt under See. ,B &P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affnm under penalty of perjury one of the Itdlowing declaratimv,
0 I have and will maintain a Cendlinve of Comenno adf-rumv for Workers Cnntpcn-
sation, as provided for by Section 37W of the Labor Code. for the performance of the
work far which Nis permit is issued.
❑ 1 have and will malnain Worker's Compensation Insmrancq as required by Section
37M of the lahor Cale, for the pcammmme of the and, or which his permit is iswed.
My Workllja CI)mpcysmion Innssurance comer and Policy pum7)eruvcpn�q'
Carrier: i(�L_d.?�!�Policy NuM4OG
CG_RTiffC O OF COMPENSATION FROM WORKERS'
COMPENSATION INSURANCP.
(This section need not heannpletr4 ifthe Tomtit is fnrane hundred dnllan (SI W)
or less.)
1 evoify that in are perfornnmce cf the work forwhich this permit is issued, l shell
net employ any person In any nanner so n become ubbn to the Worsens' Compcn-
O Z Galion La of Qaii(nmi . Data
O Applicum _w� .(7.m,,,.ljl! n w_1M; e
N NOTICE TO APPI. If,
rung this Cenilicum of P.xcmptinn, you should
a ; become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions .,,his permit shall M deemed revoked.
Q
CONSTRUCTION LENDING ng agen AGENCY
L1 l (or which nhere issue (Sec. 3097nding agency for the performance of
II4 F the work (or which this Tomtit is issued (Sec. 31197, Civ. C.)
0 U leader, Name
T U Lenders Acidness
1 certify deal I have mad this application and snob, that the above information is
Lo) coact. l agree to comply with all city and county ordinances and state laws rcluring to QTY.
V building construction. and hereby amhmim representatives oflhis city to enmrurym the
shove- mentioned property for inspection purposes,
(We) agree In save, indemnify and keep harmless the City of Cupeninn against
liabilities. judgments, costs and expemes which may in any way tame against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
SOURCE RIiGULAI'IONS.
Slgnmam mf Applicant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fair,, building occupant store or handle hvmdous ntamriol
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532m)'I
C] Y" E] No
Will the applicant or Among building oceupaul use equipment or devices which
emir ItamNnux air ri nmmincntx m definal by the tiny Area Alr Oberlin, Management
District?
❑Yes GNo
1 hove at We hazardous moten.1, re, remena under Chapter 6.95 of the Cvll-
fernim Health & Safety Cede. Sections 25505, 25533 and 25534. 1 understand Ihm if the
building des not currently ha otenan.t�h��m}i is my resryee,dolayto nsnifythettecu,no
oftAr;Qairememswhich s ,hg l,;Uoissuancenfa Ceniricamof Occmpancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENT AL
PANELS
UP TO 200 AMPS
2(11- 1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL.
SPECIAL. CIRCIII'T /MISC.
TEMP. METER OR POLE INS 'L
F'OW17R DEVICES
SWIMMING POOL. ELECTRIC
OUTLETS— SWI'1' CUES — FIX 'I'URF.S
NEW RESIDENTIAL ELF.CTR
SQ FT.
COMMERCIAL:
NEW BLDG /ADDITION ID DEMOIATION
D
TENANT El FOOD SERv R:U
IMPROVEMENT
DOTHF.R _/t �
S0. 14. FLOOR AREA I S/SQ. PI
11
1
BUILDING PERMIT INFO
BLDG .LI!Cf PLUMB MF.CH
❑ ❑ ❑
FLEE
PERMIT ISSUANCE.
FEE
JOB DESCRIPTION
RESIDENTIAL
GSFDWI. D KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE-PIPE
[]MULTI- UNIT OSTRUCI'ORAL
MODIFICATION
D INTERIOR 0 CHIMNEY REPAIR
IMPROVE ENT 0SWIMMING POOLS
0 BATH RIiMODIEIJRIEPAIR 0 DEM01.1'I'ION
D OTHER
VALUATION
DBD4e
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF, AREA. COND.
COMMERCIAL:
NEW BLDG /ADDITION ID DEMOIATION
D
TENANT El FOOD SERv R:U
IMPROVEMENT
DOTHF.R _/t �
S0. 14. FLOOR AREA I S/SQ. PI
OFFICE
OCT 2 7 RECD
My Uf lourthI IINU
TOTAL. :
PLUMBING PERMIT
FLEE
PERMIT ISSUANCE.
ALI ER —DRAIN & VENT — WATER Oz /o
VALUATION
DBD4e
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOF, AREA. COND.
STORIES
FIXTURES — PER TRAP
GAS — EA. SYS'1'FM -1 INC. 4 OUT LEI
OCC. GROUT'
E
GAS — EA. SYSTEM OVER 4 EA)
GRIEASU NDU9'TRI. WANT If IN'TBRCEVI'OR
BUILDING DIVI
GRHASETRAP
PLANClIIiCK PF.F.
SEWER — SANI rARY — S'TORM EA. 200 Pr.
IiNIIRCY I >lili
wYrER HEATER WNEWMLECTR
GRADING ItiF.
WAI17R SYSTEM/TREATING
SOIhS PI ?li
WATER SERVICE
PAID
NEW RESIDENTIAL PLMIL SQ, IT.
owe ceipl a
TOTAL:
TOTAL.:
BUILDING I'lili
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERM[ O ISSUANCIi
VI.EC'I'RIC FEE
ALTER OR ADD'TO MECH.
PLUMBING FEE
AIR HANDLING UN1 "1'0011,000 CFM)
MEC I IAN CAL PHH
AIR I IANDIJNG UNIT (OVER 113,000 CIM)
CONSTRUCT ION TAX
EX IAUST HOOD (W /DUCT)
IIOUSING MITIGATION FE
HExrING UNIT TO 100.000 BTU)
HEATING UNIT (OVER 100 0011 BTU)
PAID
VENTILATION PAN (SINGLE RUSH))
Dare Receipt W
BOILER — COMP (3HP OR 100,003 BI 'U)
TOTAL
BOILIiR — COMPIOVER IIXI,aW Bl'UI
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MFCH. SQ. IT.
OFFICE