25016DLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
TY OF CUPERTINO U&BI
APPLICATION/PERMIT PLUMISING-MSIDENTICAL
BUILDING DIVISION IIIIILDINI: PRO]RC'T IDENTIRICA
.DING ADDRESS: 1.
LICENSED CONTRACT'OR'S DECLARATION
pyZ Ihereby affirm that l am licensed under provisions ofaader 9(commencing with
Pico Section 7000) of Division 3 of the Business and Professions Code, and my license is in
Fy�F fall fame and of /- G)a OGtL
GL License Cl Lie.# 07
yQy Date ContnMinr
F 4 ARCHITECTS DECLARATION
OZ -0 I ander rand my plans shall be used as public records.
FNt�
Y� Licensed Professional
8m OWNER -exempt front
DECLARATION
Ot I hereby affirm that I am exempt from the Cessions Co License law for the
OD�Om which followingseason.
Permit
to consume5. r,
aliexsandve. disians Code: Any city orcounty
mal which requires a permit tm construct, alter, improve. Jcmolish, or repdr any structure
Q�
prior toiisissuance, also requires the applicant for such permit toriileasigned statement
IZp that he is licensed putsuam:n the provisions of the Contractor's License Low(ChaNer
„y
eMo 9(rommencing with Section 700)of Division 3 of the Businw
eand Professions Cade)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
4 Section 9131.5 by any applicatnfor apomthsubjects the applicant toacivil penalty of
'y' Q or more than five hundred dol lam($5W).
se: ❑ 1, as owner ofthe property, ormyemployas with wages as their solecom,enation,
will do the work, and the structure is not intended or offered for sale (Sec. 9044, Business
and Palfi wit ns Ciro: Tho Contown.e. License Law does not apply to ua nwner of
propeny who builds w improves thereon, and who docs such work himself or through his
own employees, Provided that such improvements ate not intended oroffined for We. If.
however, he building or improvement is sold within one year of completimn,theowner-
builder will have the burden of proving that he did nm build or improve for purpose of
xale.).
❑ I, as owner ofthe property, am exclusively contracting with licensed contractors to
anstmcn the pro)act (See. 9044, Business and Professions Code:) The Contractor's
License Law does not apply to an owner ofpson my who builds or improves thereon,and
who contain for such pmjens with ecantmmm(s) licensed pursuant to the Contactors
License Law.
❑ I ass exempl under Sec , B & P C far this reason
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby offimUlia, l have a certi0ale ofcansenrto self insure, or a cenlBcam of
Workers Compensation Insurance ora cenifed cop thereof (Sec.3 M. Lab CJ which
covers.it yfe'.x:art� `:n?pl �h.P
IMficy # _ �6l
Company '�
❑ 0Bad py is hereby famished.
Cenified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section aced nm be completed if thepenait is (aroma hundrM dollars ($I W)
or less.)
I cenify that in the performance of the work for which this permit is issued.) shall
not employ any person in any nowner so in to become subject to the Workers'
Campensolionl-ma.fCalifornia. Date
Applicant
NOTICE; TO APPLICANT: '. Commaking This Certificate of Exemption, you should
becomesubject m the such pr Compensation per itionsofthelabor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION 1. ENDING AGENCY
1 hereby affirm that hem is a construction lending agency for the performance of
the work for which this pemrit is issued (Sec. 3099, ON. C.)
Lendw's Name
lenders Address
I cenify that I have read this application candidate that the above information is
meet. l agree m coindy with all city and county ordinances and state laws relating to
building construction, end hereby aumorizn representatives of this city o enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgmeals, costs andexpenun, which may in any way accrue against said City
in consequence of the grunting of this permit.
Signatureof Applicant/Contactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding occupant atom or hondlo haxardous material
us defined by the Cupertino Municipal Code, Chaprer 9.12, and the Heahh and Safety
Cade, Section 25532(x)?
❑ Yes No
Will theapplicant orfumte buildingoccuparduwcquipmenlordeviceswhich emit
hazardous e r conmminsu as pefined by the Bay Area Air Quality Management
Disuin? [§'/
Yes No
ID
1 have read the hazardous materials requirements under Chapter 6.95 of the
Health & Safery Cade, Sections 25505, 25 13 and 2.5534. I unJersmnd thm
if theif buildinor
g, lb tris yrespnnsibilitymnotify the
occupant of the res n'b n s m Drior o room. of a Cenifikam of
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL.
PANELS
UP TO 200 AMPS
OUTLETS -SWITCHES -FIXTURES
NEW RISIDFNTIAI. ELECT, _SQ. PI'.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK PLOW PROTECT. DEV ICE
DRAINS- FLOOR, ROOF, AREA, CONI,
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS-EA.SYSTEM-OVER4(EA)
GREASEANDUSTRL WASTE. INTERCHPTO
GRE,SETRAP
SEWER - SANITARY - STORM M. 20017,
WATER HEATER W/VLNT/BLECTR
WATER SYSTEM[FRFATING
NEW RESIDENTIAL FINE. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MSCIL
AIR HANDLING UNIT (TO IB,BDO CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
RXIIAUS'T HOOD (WMUM )
HEATING UNIT GO 100,000 BTU)
HEATING UNIT (OVER I00,M0 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 1 W,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECII. SQ. FT.
FCC
FEE
61 778-.'"
FEE SUMMARY
GNADING FEE
ROILS FEE
ENERGY ME
PAID 4 _Z
BUILDING FEE
SEISMIC FEE
F.LEMIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date Receipt#
TOTAL:
ISSUANCE DATE
Ilia RV
DU
0'
25016'
SANITARY NO.
APPLICATION SUBMITTAL DAT:
NIC
0
CONTROL#
7 2-71
CFP
BUILDING PERMIT INFO
BLDG E
ECT PLUMB NILE11
JOB DESCRIPTION
l
SO. FT. FLOOR AREA IE/SO. FT.
FCC
FEE
61 778-.'"
FEE SUMMARY
GNADING FEE
ROILS FEE
ENERGY ME
PAID 4 _Z
BUILDING FEE
SEISMIC FEE
F.LEMIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date Receipt#
TOTAL:
ISSUANCE DATE
Ilia RV
DU
0'