31212APPLICANTTO FILL IN INFORMATION WITHIN
BUILDING DIVISION
N'Inalai
- USE BALL POINT PEN ONLY
2 QOO I ❑ Consultant Fes Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Cpwith Section7000) or'" "Division 3oflhc Bmineasvnd Prnfcasians Cude, dmy license is
F CZ) nfullfnceanJefiect.
Jul- l- License Class r I Lic. X % Y�
W S N Dam Conlmctor�ll 1
[-Cm ARCIIITE(.TS DECLARA "f
Z 1 mndmmad my plate shall be used as public retards
OZr-O
l-I4 F., Licensed Licensed Professional
NH OWNER - BUILDER D17CLA14ATION
C W Q I hereby affirm thm 1 am exempt from the Conlmemr's License Law for the
3 O y U following remon. (Section 7031.5, Business and Prdcssiom Code: Any city or c .... my
4 F- which mauims a permit to comfort, alter, improve, demolish, or repair any stmcmre
prior to ids issuance, ulsinonlireetheupplic art l inmoh penon, o lil ... i, nI xmmment
that he is licensed pursuing the provisions of the Commemes License Use (Chapter 9
OO(commencing with 4elion1IXN1 of Ili, Iona 3 of the Beanes, and Poll a.Juus Cndo) or
d that he is exempt therefrom and the basis for the alleged exempion. Any violation of
°•
Section I'll 1..5 by any "helm ter u penal subject, lim."he it to d civil penally al
F, nod mom than five hundred dollars ($500).
C❑ I. as owner of the property, or my employees with wages as lhcir sole compensation,
will do the work, and the structure is not intended oroffered for sale (See. 7014, Business
G and Professions Code: The Cranstnr's 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 hoprovemems are not intended or offered for
sale. If, however the building ur improvement is sold within one yemolcompletion, the
owner- bulWer will have the burden of proving that he did not build or impmve for par
pose of aide.).
❑ 1, as owner of the property. am exclusively contracting with licensed cmntmanrs to
construct the project (Sec. 7044, Business and Professions Code.) The Commit. "' Li.
can. Law dots not apply In an owner of property who bidilds M improves thereon, and QTY,
who contracts far such projects with it commnorod licensed pursuant to the Contractor's
License law.
[3 I am exempt under Sec. ,B &P C for thiss Mason
Owner
WORKER'S COMPENSATION DECLARATION
1 hereby iffmn under penally of perjury one rf the following doelamlions:
❑ Hose sad will maintain a Certificate of Consenno self-insure for Worker's Camper.
onion, as provided lo, by Scelion 3700 ol'the Labor Code, for the pr,l tame of the
w
it for which This permit is issued.
I have and will mainain Worker's Conipaimatioo Insurance, as required by Section
3 of the Labor Code. for the performance of the work for which this parrot is ismod.
Ca Work Cumpcn: torn Insurance carrier and Policy .amhra
Cvrtier. Policy FROM
Bk IC L'
COMPENSATION WORKERS'
COMPENSATION INSURANCE
(This cation neW not be complaW II'dm permit is future hundred dollars (SI001
or ass.)
I acidly not in the performance of the work for which this permit in issued, I shall
not employ any person in any manner so as to became subject to the Workers Camper
,Z sell.. Laws of California. Dale
2 Q Applicant
h NOTICE TO APPLICANT: If. after making this Cenificste of Ba,maptimn, you should
a become subject to the Worker's Compensation provisions of the Labor Code, you most
Ltd forthwith comply with such provisions of this permit shall be deemed revoked.
Q
� CONSTRUCTION LENDING AGENCY V Q I hereby affirm that there is a crmuumirn lending agency for Performance of
V. F the work for which this permit is issued (Sec. 3097, Civ. C.)
O U Lcoder's Name
{21 Larder's Address
Om 1 earthly that 1 have read Nis application and slam that above Information is
ti
h corea. I agree to comply with all city and county ordinances and state laws relating to QTY
CJ Z ngaoc enJ for ay
ith,wa- memiured propenY for inspection Pureryprrseesse. nntives nl Odvcity t. enmrnpnn the
(We) agree t. save, indemnify and keep harmless the Cily of Cupertino against
liabilities, judgments, costs and expenses which may in any way a.me again. said Cily
in cons, ante of the grunting of Ills pennil.
APPLIC UNDERSTANDS AND,WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Wi he applicant or E. men ilding occupant store or handle hazardous material
as defined 1 the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sects n 25532(x)1
p ew,
Will the applicant or future building occupant use equipment or devices which
nit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
Yes
haw r' the hazardous mnmrinls reauimments under Chapter 695 of the Cali
forma Health fall Code. S «tints 25505. 25533 and 25534. 1 understand that if the
building dceem re ally have ammmn.Ihm it is my respmsihitil, m not i fy the cempum
ofthe l� me I wiljch must be amt dpno issuance of. Cenificale 4f Qcairear,.
❑,
ELECTRIC PERMIT
FEE
JOB ESCRIATION
RESIDENTIAL'
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION L1 PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCFURAL
MODIFICATION
❑INTERIOR C1 CHIMNEY REPAIR
IMPROVEN�T
❑BATH RE I DARIjPAIR 0DEMOLITION
[2 Gal �
PERMIT ISSUANCE
APPLIANCES- RESIDENTIAL
PANELS
UP TO 200 AMPS
201- 1000AMPS
OVER IM0A PS
SIGNS ULEC'TR
SPECIAL CIR /MISC.
TEMP. MF'1'TR OfAvrl '
C31 NEW BL &/s{NJI, ION T ❑DEMOLITION
: ANT t'lk,, ❑FGODSERVICH
POWER DEVICES
- FIXTURES
ECTR SQ IT.
PERMIT I PEE
ALTER - DRAM' VE - )OATER(EA)
NACK FLOW PR f: F E
DRAINS- FTOOR, kOOP. EA. COND.
FIXTURES -PER TRAP 2 ��
GAS - EA. SYSTEM -1 INC. 4 OUfLE'1'S
GAS -EA. SYSTEM OVER 4 (HA)
GREASFANDUSTRI. WASTE INTERCEPTOR
GREASETRAP
SEWER- SANITARY -STORM EA. AIO IT.
WATER HEATER W /VENT/ELECTR
WATER SYSTEMURP.ATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. IT.
MECHANICAL PER MIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER MIKE CFM)
EXHAUST HOOD OVIDUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP(3HP OR 100.000 BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. 14.
OFFICE
$/SQ. FT.
lunG I
�� �
STORIES f .CON!
ENERGY FEI, wJI 1 %�M I— .I
SOILS
PAID
De Receipt p
BUILDING
PAID pate ReceiPtN I
TOTAL:
r