S 0750FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN
CITY OF CUPERI'IN
BUILDING DIVISION
CONTACT.
APPLICATIONIPERMIT
1 hereby affirm that I .m licensed -Filer Pmoisture of Chapier) (commencing
with Section 700D) of Division 3ofthe Business and Professorin"al and my license is
iI n full force and ercegy'
n..... rat« Lm. # T
L V'
H101gT�H
❑ Consultant Fees Paid by Applicant (Initial)
n;L 1 understand my plans shall he used as public records
O
Licensed Torose enel
? OWNER -BUILDER DECLARATION
1 hereby affirm that 1 Fm exempt from the Contractor's License Law far the
a U following reason (Section 7131.5. Business and Professions Code: Any city or county
W h which requires a permit to cimxwm, alter, improve, demolish, or repair any nmeture
�d prior in its issuance, also requires the applicant for such Domain o file a signed statement
that he is licensed pursuant no the provisions of the Contractor's License Law (Chapter 9
(commencing with Scrion 700( of Division Surma Business and Prnfossions Code) or
o eC that he is exempt therefrom and the basis for the alleged exemption, Any violation of
m. m Settinn 7031.5 by any applicant for a permit,.blots the ap,licam to a civil Penally of
Cnot marc than five hundred doll.,, ($500).
❑ 1, as owner f the property, or my employees with wages as their ole wmpemmion,
will dothovork,andthe strichim isnot imendede.Ioned farsalopire. 7044, Business
aro and Professions Code: The Compounds License Law docs not apply to an owat' of
progeny eche fair, nr reproves thereon, and who doe, such work himself nr thrnugb
his awn employees, provided that such improvements are not intended or offered for
Sale. If, however, the building or improvement is sold within one year of eompletion, the
proper -builder will have the burden of proving that he did not build car improve for pur-
pose of sale.)
D 1, as owner of the property, am exclusively contracting with licensed conuacmrs m
,mmornet the project (Sce.7044, Bmsimses and Profession, Code:) The Contractor', Li -
se law does nut apply to an owner of property who builds or improves thereon, and QTY.
who contract, for such projects with a comescom(,$) licensed pursuant India Contractor's
License Law.
an, exempt under Sec. ,B& P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I I hereby ofbrm under penalty of perjury one of the following declarations:
Dor,renpmvide dmf ,rib,l SeaCtonnifty0,,CtheaLseab.r C.dei,nfsourreth[oe rpWeroorkemrsmccofthe
work I,,, his], thispermih issued.
have and maintain s Compensation In .anee, as Finished by Section
yhe Cuba, oda, for lhepeffomanc of thstuck for which his permit is issued
M Wrzker'e Co.
en tin Insurvn prier and Policy,. �'%�ry �ip�/
Carried Folie
CERTIPICOF EXEMPTION FROROMWORKERS'
COMPENSATION INSURANCE.
(Thio section necA not be completed Fillip prstnit isfnnmchundred dolhirs ($100)
or less.)
1 certify that in the performance of Ne work far which this permit is issued, l xball
not employ any person in any manner.so as to become sphicat to the Workers' Compen-
,7. cation law, of Coliform. Data
Z O Applicant
NOTICE TO APPLICANT: If, after making this Cedifica:e of Exemption, you ebould
aibecome subject to the Worker's Compwsatian provisions of the Labor Gde, you must
W forthwith comply withsuch provisions mr his permirshall be deemed revoked.
ee.. Q
q CONSTRUCTION LENDINGAGENCY
agent
U O I for which rat the there is s ed (Sao tion lending agency for the performance of
w'H the work or which this permit is issued (Sao 3fY07, Cie CJ
Q Lenders Name -
W l.endod1 Address
y gree that 1 have read this city
and coup and ,tam that the shove Information is
.r N wired I agree to comply with all city and county ordinances o, and nam laws r upon the QTY.
V building wnmudiemand hereby amhiar purposes representatives city memerurym the
above -more)., propamr 4virtpotionpurposes.
(Wo)agreeto eve, indemnifyesJkeep may
the City
ruCupertinoid City
liabilities,consequence
nce of thecosts and expenses which inay in any way accrue against said City
onICAN ec UNDERSTANDS
S this AND WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
1�A,dodFnUCHAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Health add Safety
Code, Sermon 25532(a)?
Dyes bo
Will the applicant or fufwure building ..part use equipment our devices which
emit hazardous air conmmiwms lie defined by the Bay Area Air Quality Management
Dillict?
D Ves
1 have read the hazonlous material, mquirementa tinder C ,pier 695 of the Cali-
fornia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
building does not currently have to tenon o ; my te"Psamihilaymnmify the occupant
of the rrquimynpts which mFstk inp ,nuance of v Certificate of Wucncy.
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL.
UP TO 200 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIUMISC.
TEMP. METER OR POLE INST.
POWER DEVICES L
SWIMMING POOL. ELECTRIC
OU FLYS — SWITCHES — FIXTURES
NEW RESIDFN'I IAL ELECTR SQ FT.
S ""V 0750
NITARY NO. APPLICAl10N SUBMI i'I'AI.
�2�(6
NIC' /r�y�'CON�L#
BUILDING PERMIT INFO
JOB DESCRIPTION
RESIDENTIAL
$ISQ. Fir
❑SFDWL
❑ KITCHEN REMODEL
D ADD] rION
❑PLUMBING RE -PIPE
OMUL7'1-UNIT
E3 STRUCTURAL
DRAINS— FLUOR, ROOP,ARF.A.COND.
MODIFICATION
El INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
D BATH REMODELREPAIR
D DEMOLITION
D OTHER
PLANCHECK FEE l
SEWER — SANITARY — STORM FA. 200 IM
COMMERCIAL:
❑NEW BLDG/ADDITION L1 DEMOLITION
WIENAN'I ❑ FOOD SERVICE
OFFICE
SQ. P. FLOOR AREA ""
6
,CI r Ur UUrCMIIN
$ISQ. Fir
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTHR—DRAIN & VENT—WATER (EA)
VALUATION
VV
BACK FLOW PROTECT. DEVICE
DRAINS— FLUOR, ROOP,ARF.A.COND.
STORIES
OCCGROUP
TYPECONSTRUCT
APN
FIXTURES — PER TRAP
GAS — EA. SYSTEM -I INC. 4 OUTLETS
GAS — HA. SYSTEM -OVER 4 (EA)
GREASPIINDUS'put, WASTE INTERCEPTOR
r ' , BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE l
SEWER — SANITARY — STORM FA. 200 IM
ENERGY FEE
72
WA'I ER HEATER WNENDLLECTR
GRADING PER
WATER SYSTEM?REATING
SOILS FEE
WATERSERVICE
PAID
Data Recalils#
NEW RESIDENTIAL ELAM. SQ, IT,
TOTAL:
BUILDINGFF.F.
' MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC LEE
ALTER ORADD"I0 MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000CFM)
EXHAUS'PIIOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 1110,000 BTU)
EHOUSINGMITIGNTION
ceipt#
VENTILA'T'ION FAN(SINGLE RESID)
BOI ER—COMP(3HPOR 100,01108TU)
'TOTAL:
BOILER—COMP (OVER 100,000 HTU)
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQ. Fn
OFFICE