28461APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.- USE SALL'POINT PEN ONLY .
CITY OF CUPERTIN0 - BUILDING - ELECTRIC
BUiI,DINC DIVISION APPLICATION/PERMIT PLUMBING - MECHAmt
i 220 'STW buns
SEC
t;;1,t)J �� O p �� CEORS NAM2 ,��� �u��µ�IC NO
s ICJ tS(j(,/ '�p-f� NIC
RCHITECT/ENGINEER: .1 ❑
Ju.0 vt abxt
I hereby affirm that I am licensed under pmvisions of Chapter 9 (commencing
with Section]Ofl(pofDivisio r3 fill BUSlneaa�and`Paofes "sionsC de, and mylicwse is
in full force and effeclCJ' iV 692
LiciiLicense Cla(t�
l Cnntrnr r >q
ARCHITECTS DECLARATION
1 understand my plans shall be used as public meor it,
- -
Lincred Professional
OWNER- BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contract.,', License Law for the
following wever. (Section 7031.5, Business and Professions Code: Any city or county
which require, a permit m smou in, utte, improve, demolish, m'repsir any structure
prior to its issuance, also reunions the applicant for loch permit to Ole a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is 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 a civil penalty of
not more than five hundred mothers ($500).
C 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If. however, the building or improvement is.sold within one year of completion, the
owner- huilder will have the burden of proving that he did not build or improve for pur-
pose of
i] I, as owner of the property, am exclusively concocting with licensed cdntracmrs to
construct the Project (Sec. 7044, Business and Professions Cale:) The loam....'. Li-
cense Law does not apply to an owner of property who builds or improve, thereon, and
who contracts for such projects with a ehncomons) licensed pursuant to the Contractors
License law. _
C 1 am exempt under Sec. , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cvr ifcad of Consent to self -insure for Workilos Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
X have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
28461
❑ Consultant Fees Paid by Applicant (Initial) BLDG EikEqV PLUMB MECH
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02MAMPS
SIGNS ELECTRICAL'
SPECIAL CIRCUIT /MISC.
TEMP. METER OR POLE INST.
POWER DEVICES,
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES- FIXTURES
NEW RESIDENTIAL ELECTR S(
QTY. PLUMBINGPERMIT I '%EE A
COMPENSATION INSURANCE
(This section need net bewmpleted ifthe permit is throne hundred dollars ($ I W)
or least,
Icenify that in the performance ofthe work for which this permit is issued, I shall
not employ any Person in any manner so as to become subject to the Workers Cluster-
0 Z earner Laws of Cnlifc nia, Date
4 0 Applicant
y NQfICF, TO APPLICANT. If, after making this Certificate of Exemption. you should
C-! become subject ,, the Worker's Comp hunumn pmvisions of the Leber Code, you most
fanhwth comply with such provisions or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
U 0 I hereby affirm that he isa construction lending agency for the performance of
LSs . the work fore this permit in issued (Sec. 3197, Civ, C.)
0 U Leader, Name
Gin Le dens Address
1 certify that I have read this application and state that the above information is
- Fr U5 correct. I agree to comply with all city and county ordinances and state laws rebuff ng m QTY.
U building constmetion, and hereby authorize representatives of tlda city to enter upon tbn
above -reemmued property for inspection ufew,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
inconsequence 'he gmntingn permit.
APPLIC ,fit d�fNDERSTANDS� WILL COMPLY/RH ALL NON -POINT
HAZARDOUS MATERIALS DISCLfY§URE
Will the applicant or future building occupant store or handle hmordous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cade: Section 25532(a)?
0're, El No
Will the applicant or future fimIdi ng occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Managentenl
District?
Dye, C No
I have read the hmardeas msanals requirement, under Chapter h.95 of Ne Cali -
fomia Health & Safety Code, Suctions 25505, 25533 and 25534, 1 understand chat if the
building does not currently have tenant. that it is my responsibility to really the occupant
of the requireomnfx which must be met prior o Issuance of a Cenlfiate of Coupon,
Owner or malmozed agent Date
ALTER -DRAIN &' VENT - WATER RDG
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES -PER TRAP,
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM-OVER 4 (EA)
GREASEONDUSTRL WASTE INTERCEPTOR
GREASEI'RAP
SEWER - SANITARY - STORM EA. 200 Ff.
WATER HEATER WNENT /ELECTR
WATER SYSTEM/TREADNG
WATER SERVICE
NEW RESIDENTIAL PLMB. , SQ. FT. ,
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,001 CFM)
AIR HANDLING UNIT (OVER 10,1100 CFM)
EXHAUST HOOD (W /DUCT)
HEATING UNIT TO 100,010 BTU)
HEATING UNIT (OVER 10000 BTU)
VENTILATION FAN (SINGLE RESID
BOILER -COMP (3HP OR 100,0110 BTU)
BOILER - COMP (OVER 100,000 BTU)
OFFICE
SQ. FL
OMM R IA
C NEW BLDG /ADDITION El DEMOLITION
C TENANT ❑FOOD SERVICE
IMPROVEMENT
C OTHER �" ��
SQ. Fr. FLOOR AREA $/SQ. P
i
VALUATION ,
STORIES TYPECONSTRUC
PLANCHECK FEE
ENERGY FEE
GRADING FEE '
SOILS FEE
PAID
Date Receipt
I .TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
MECHANICALFEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID 17a.
Date p[ M
'
TOTAL:
Cfl r yr uUrtIiI7'qU
FEU
JOB DESCRIPTION
RESIDENTIAL:
C SFDWL 11 KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
.. C MULTIUNIT 0STRUCTURAL
MODIFICATION
- ❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT -
C BATH REMODEL(REPAIR C DEMOLITION ,
COT14ER
�—_
QTY. PLUMBINGPERMIT I '%EE A
COMPENSATION INSURANCE
(This section need net bewmpleted ifthe permit is throne hundred dollars ($ I W)
or least,
Icenify that in the performance ofthe work for which this permit is issued, I shall
not employ any Person in any manner so as to become subject to the Workers Cluster-
0 Z earner Laws of Cnlifc nia, Date
4 0 Applicant
y NQfICF, TO APPLICANT. If, after making this Certificate of Exemption. you should
C-! become subject ,, the Worker's Comp hunumn pmvisions of the Leber Code, you most
fanhwth comply with such provisions or this permit shall be deemed revoked.
z. CONSTRUCTION LENDING AGENCY
U 0 I hereby affirm that he isa construction lending agency for the performance of
LSs . the work fore this permit in issued (Sec. 3197, Civ, C.)
0 U Leader, Name
Gin Le dens Address
1 certify that I have read this application and state that the above information is
- Fr U5 correct. I agree to comply with all city and county ordinances and state laws rebuff ng m QTY.
U building constmetion, and hereby authorize representatives of tlda city to enter upon tbn
above -reemmued property for inspection ufew,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
inconsequence 'he gmntingn permit.
APPLIC ,fit d�fNDERSTANDS� WILL COMPLY/RH ALL NON -POINT
HAZARDOUS MATERIALS DISCLfY§URE
Will the applicant or future building occupant store or handle hmordous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cade: Section 25532(a)?
0're, El No
Will the applicant or future fimIdi ng occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Managentenl
District?
Dye, C No
I have read the hmardeas msanals requirement, under Chapter h.95 of Ne Cali -
fomia Health & Safety Code, Suctions 25505, 25533 and 25534, 1 understand chat if the
building does not currently have tenant. that it is my responsibility to really the occupant
of the requireomnfx which must be met prior o Issuance of a Cenlfiate of Coupon,
Owner or malmozed agent Date
ALTER -DRAIN &' VENT - WATER RDG
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES -PER TRAP,
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM-OVER 4 (EA)
GREASEONDUSTRL WASTE INTERCEPTOR
GREASEI'RAP
SEWER - SANITARY - STORM EA. 200 Ff.
WATER HEATER WNENT /ELECTR
WATER SYSTEM/TREADNG
WATER SERVICE
NEW RESIDENTIAL PLMB. , SQ. FT. ,
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,001 CFM)
AIR HANDLING UNIT (OVER 10,1100 CFM)
EXHAUST HOOD (W /DUCT)
HEATING UNIT TO 100,010 BTU)
HEATING UNIT (OVER 10000 BTU)
VENTILATION FAN (SINGLE RESID
BOILER -COMP (3HP OR 100,0110 BTU)
BOILER - COMP (OVER 100,000 BTU)
OFFICE
SQ. FL
OMM R IA
C NEW BLDG /ADDITION El DEMOLITION
C TENANT ❑FOOD SERVICE
IMPROVEMENT
C OTHER �" ��
SQ. Fr. FLOOR AREA $/SQ. P
i
VALUATION ,
STORIES TYPECONSTRUC
PLANCHECK FEE
ENERGY FEE
GRADING FEE '
SOILS FEE
PAID
Date Receipt
I .TOTAL:
BUILDING FEE
FEE SEISMIC FEE
ELECTRIC FEE
MECHANICALFEE
CONSTRUCTIONTAX
HOUSING MITIGATION FEE
PAID 17a.
Date p[ M
'
TOTAL:
Cfl r yr uUrtIiI7'qU