S0001 B0276APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.MECII RICAL PERMIT NO 0 2 7 6
BUILDING DIVISION APPLICATIONIPERMIT rl.umxlrvr.�nu cD,kNICA1. SOoo�
IIUII,DING PROJRCI' IDFNFIFIPA'TION &0276
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PHONE: C 'HA OR'S NA E: Sk ` - LIC Nll: NIC
LICNOP. AD F NkJ� ❑
AUA —7' 3 PAA ec
PHONE!
Ik a ❑ Consultant Fees Paid by Applicant (Initial) BLDI
❑
OI herehy ufBrnp
t Ihal I uta licensed under mvivians Of Chirpier 9 (commencing
with Section uplift of Division J of the Rosiness and Pmfcsions Code, wnjmy license is
FO in full force and effca.,_
C Lica9�w Lice ^
Q
.at.
Contmc
AHCHITECFS DE . t 10
F N Z_ I understand my plana shall be umd as public rear
OZNO
F4 t: W Licensed Prnfcatmml
OWNER -BUILDER DECLARATION
Xz ee C Q 1 hereby affirm that 1 am exempt from the Crull actor's License Law for the
W g rcumn. ISutiun ]Ili 1.5. Broin and Pmfexaions Code: Any yciIy or county
ici 3
yQ which requires a permit to conies), alter, improve, demolish. Or repair any ewdurc
F,LL0.1 prior to its issuance, also requires Ne applicant (a, such parmiuo file asiynedsmlement
F�yy[yN that he is licensed pursuant Io the provision, Olds, Comment", license Law (Chapter 9
MEMO (commencing with lection 7x0)"(Dix men Sul he lucinexs and Pmle<slam Coda) or
L Xo K that he is cxcmpt therefrnm and the basin for the alleged exemption. Any vinlaion of
W Section ]11]1 S by any spill scant for a Iwnnit subject the applicant nt a civil penalty of
not more Oran five hundred dollars ($500)
SO O 1, us owner ofthe.rupcnY, or mY emploYcn with wages us their sole mmpemm�ess
b M11d"rhewontuidtbe snucelrennul imm�dcrinntllkrrd hoetele (Sea. 71Uq. Boniness
W; m and Itnfesxinnx Cade: The Contractor's License Law does not apply at an "weer of
propcny who builds or improves thereon, and who dues such work himself or through
his own c,np.oyce........ tied 'ha such ingnnvcmeoa, era all intended m offered for
sale. If, howm'em the building or improvcmenl is sold within one Year of completion, the
owner -builder will have the burden of proving that he did not build or improve for pur-
pwe of vale.).
0 has owner of the property. am exclusively contracting with licensed contractors bt
m.amct the project (Sec. ]IkW, Business and Professions Cude:) The Contractor's Li -
cause lawdoes nal apply sono owner (If property who builds or improves thercnn,and QTY.
who contracts for such pmjmts with a cantmctods) licensed pursuant) the Contmclnrs
Littnsc Law.
❑ I am exempt under See. . If & V C far Ibis reason
Date
1 er WORSE ia'9 COM PENSARON DECLARATION
I hereby aRmt under penalty of perjury one of the following dedaratinn.s
.
't] 1ludoc and will nrnitnain a Certificate of Consent m self -insure for Workers Compen-
.sati ar as provided ter by Solation 3700of the labor Ciba lot the faunn mance of the
d for which this permit is issued.
t�a+� I Inas a l will minium Worker's Comlencation Insurance, as required by Section
391If of the Labra Code, for the paidemanee ol'the work for which this puma is issued,
\/ Cy Wor c -'I pct nnlnsumncc carrierIte
la IIy Naynn�;re—� �Z
//y` iiYY CIiHI'IF CA'IT OP I SEMP1'ION FROM WOHR[H5'
COMPENSATION INSURANCE
1'I'In, nation need ern be c..ntpletod i I'Ihe permit is forme hundred dollars (SI W I
,or lcssJ
1 certify that in the performance ofthe work fur which this permit is issued, l shall
nn' m"a"y any pcm"n in any manner m as m h ' t vuhjec' nt the Wnrkess' Comlwn-
O z ration Laws. 1. omia. Datc - -_
z O Arr1i .�tt
U.,r 1. r PI'hIC N ` Met making This Cur ificae of P ompriom You s'bould
becnttc subject to the Wor ce% Compensation previsions of the Islam Code, you must
Wti fnnhwitheontply with such prevision., Or this permit shall M deemed Invoked.
a�
7z CONSTRUCTION LENDING AGENCY
U 0 I hereby affirm that there Is a construction lending agency for the performance of
r- the work Lou which this peril Is Issued (Sec. 3097, Clv. C.)
Q U Lcnder'v Name
17" illLender's Milos,y 1 cenify the, 1 have read this application and Imre Ilan the ubnva,ffnncuion ix
(y" to correct. I agree to comply with all city and county aNinances and store laws relating a' QT1
(.) Z I+uIlion, einstruction, and hereby truth it. raprenentaivev I' his
oilymeme, upon tM1e
aMvomentioncd Property for imspeninn purpnas.
(We) agree rt save, indemnify and keep harmless the City of Cupalina agaimt
liubilitics, judgment'. "I'll and expenscn which many in any way accme agaimt mid City
in comequeace of the granting of 'his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE! REGULKHONS,
Signature of Appl Icnnl/Conaacutr Date
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant "r future building accupam'mre or handle fraeiolous material
as defined by the Cuper'inu Municipal Code, Chapter 9.12, and the Health and Salary
Crude. Section 25532(a)u
❑Yes F7 No
Will the applicant or future )wilding occupant use equipment or devices which
emit htzarials air cnmminumants as defined by the Bay Arca Air Quality Management
District!
❑Yes GNO
I have re:d the hvmdoux mandat rtquimments under Ch:mar 6,95 01 the Culi-
fomia Health & Safety Code. S«fions, 3505. 25533 ad 2_55}1.1 understand thin if the
building does ern rnncmly have it senntn, fro it is my responsibility to notify the mcule nt
of the requirement which must be ten prior w issuance of a Centrism, of OxOPancY.
Owner or vufhnrisd agent Dlnc
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANEL S
up Or 201) AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'1➢M13C.
'Ds.MP. A1E'I'IiH OR POLE INtiI'. /
POWER DEVICES
SWIMMING POOL ELECTRIC
OU'1'1-IiTS - ti W l'I Cl{Ii5 - I'I X'I'U RES
NEW RESIDENTIAL ELECTR SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & III WATER (IiA)
BACK FLOW PRDI'IiCT. DEVICE
DRAINS - FLOOR. ROOF, AREA. COND.
FIXTURES -PER TRAP
GAS - IiA. SYSTEM -1 INC. 4 OUTIJd1 S
GAS'- EA. SYSTEM -OVER q T.G
GREASUINDUSTRI. WASTE INTERCEPTOR
GREASE 'I'RAI'
SEWER - SANITARY - STORM F.A. 210 F I:
WAFER HEATER WIVENI➢ELECTR
WIT 1; SYS'I EMURFAq'INC.
WATER SERVICE
NEW RESIDENTIAL. ('LMB. Sp. FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE
LTER OR ADD TO MECIL
A HANDLING UNIT (TO 10 -1 CFM)
AIR IDdNDLING UNIT (OVER 10.000 CI;M)
HEATING IINI 'IU IIXhIXD RTU)
HEATING UNIT (O sR 1 -).HA) BTU)
VENTILATION PAN (SI .LE RF_SID)
BOILER -COMP (311P OR N" HTO)
BOILER-COMP(OVER 110,1X1(1 '1'U)
AIR CONDITIONER
NEW RESIDENTIAL MI CH.
OFFICE
TOTAL:
INFO
LECF PLUMB MICH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
U KITCHEN REMODEL.
[]ADDITION
❑ PLUMBING RE -PIPE
0 MULL UNIT
71STRUCTURAL
MODIFICATION
❑INTPRIOR
❑CII MNEY REPAIR
IMPROVEMENT
0SWIl1h11NG POOLS
❑ HATH REMODHIA EPA1R 0 DEMOLITION
❑ OTHER
COMMERCIAL:
❑I NEW BLDGIADDI'HON
gIENANT
11111'ROVI:MEN'F
❑OTHER
SO. Fr. FLOOR AREA
0 DE!OOLITION
❑ FOOD SERVICE
sf?EO
SISQ, IT.
%II'y Ur k, rcr ijIvU
BUILDING DIVISION FEES
PLANCHIiCK FEE/.�
ENERGY FER
GRADING ITE
SOILS FEE w w
PAID
r Dae Hectipt g
-! 'IOI'AL.
' - BUILDING WEE!
FEE SEISMICITT.
ELECTRIC PTE
PLUMBING PEE
MECHANICAL rVE
CONSTHUC'FION'I'AX
HOUSING MTrIGATION FEE
PAID
Date Reeeile p