99110090FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
CAC -6$
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provision of Chapter 9 (commencing
with Section 7") of Div on 3 of the Best ss neand Pro ,C d,ai my license is
in full force and effect. -�
License C Lic. N
Date Contractor
ARCHITGCT'S DECL ION
I understand my plans shall he used as public recend,
OWNER -BUILDER DECLARATION
1 hereby offirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit in construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9
(commencing with Section ]WO) of Division 3 of the Business and Prefeec... Code) or
that he is exempt therefrom and the hags for the alleged exemption. Any violation of
Section 703 1,5 by any applicant for a permit subjects Ne applicant to a civil penalty of
not more than five hundred dollar, (8500).
D T. as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the stmcwre 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 employee, provided that such improvements arc not intended or offered for
,ale. If, however, the huildi as or improvement is sold within one year of completion, fee
der -builder will have the burden of proving that he did not build or improve for par -
pose of sale.),
D I, as owner of the property, am exclusively contracting with licensed commerce, to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
nse law does not apply to an owner of property whe builds or improves thereon, and
who contracts for such projects with a contractor(,) licensed pursuant to the Contmetor.v
License Law.
LCI 1 am exempt under Sec. , B & P C for this reason
Date
Poor
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury can of the following declarations:
� I have and will maintain a tion 37me of Consent to selfe,sure her Wsker', Ce of the
Nation, asprovidedetch P r mi Station 3]IXI of the Lo twr Cade, for the performene u f the
r for which this permit is issued.
I have ad will aceireard Worker's Compensation Insurance, as nesinnood by Section —
of the Later Code, for the performance of the work for which thin permit is i sued.
M Work ti umnce carrier and P
Carrier:,��� nlic Policy No.Y 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olo,waionneed not be completed iflhe permit is ozone hand Adollurs(SI00)
tcodify that i. the performanceoOhm work forwhich this peman is issued, TshdI
not employ any person in any manner so as to become subject to the WorkersConi
O,Z Nation Laws of California. Date
O Applicant
rjl NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
abecome subject to the Worker's Compensation provisions of the Lobr+Code, you must
Lit forthwith comply with such provisions or this permit shall be deemed revoked.
Q
%.
CONSTRUCTIONisoLENUINGAGENCY
affirm 1 hereby arm that rheahemis a wnstmedon lending agency for the Performance of
f gs the work for which this permit is issued (See, 3097, Co. C.)
0 U Lender's Name
W Lender', Address
1 certify that 1 have read this application and state that the above information is
1A correct. 1 agree to comply with all city and county ordinances and state laws relating to QTY
Ll,Z building construction, and hereby authorize representatives ofthis'city to enter uporde,
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless Ne City of Cupertino against
hual ities.judgerents. costs and expenses which may in any way accrue against said City
in asequence of the gram;., of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building recreant store or handle hazardous material
defined by the Cupenlno Municipal Code, Chapter 9,12.and the Health and Safety
' iCG'eJ. F-1No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air commandants as defined by the Bay Area Air Quality Management
Disnii
I ,
Y�v{,s ❑ No
1 haven d the hazardous materials requiremenw..de Chapter 6.95 of theCali-
fomie Health & Safety Cade, Sections 25505, 25533 and 25534. 1 understand Net If to
orliingdnesnrteo nllyhavey tenare that it is my responsibility m notify the occupant
of the 41 Is !as,r ret prior to issuance of a Ciminero if Qcgisfia,
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
DO rUE:TS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTS
IOM
n
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER HUo
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND,
FIXTURES - PER TRAP
STORIES TYPE CONSTRUCTION
i- dl -VJ
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
FEE
JOB DESCRIPTION
RESIDENTIAL:
D SFDWL D KITCHEN REMODEL
D ADD7IION El PLUMBING RE -PIPE
D MULTI -UNIT D STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
D BATH REMODEL/REPAIR ODEMOLITION
D OTHER
GREASOINDUSTRL WASTE INTERCEPTOR
BUILUMODIVISION
FEES
GREASETRAP
PLANCHECK FEE.
SEWER -SANITARY -STORM EA. 200 FT
ENERGY FEE
COMMERCIAL,
1-1 NEW BLDG/ADDITION ❑DEMOLITION
{`TENANT ❑ FOOD SERVICE
IMPROVEMENT
D OTHER
GRADING FEE
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER HUo
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND,
FIXTURES - PER TRAP
STORIES TYPE CONSTRUCTION
i- dl -VJ
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
AN
GAS - EA. SYSTEM-OVER4 BA)
GREASOINDUSTRL WASTE INTERCEPTOR
BUILUMODIVISION
FEES
GREASETRAP
PLANCHECK FEE.
SEWER -SANITARY -STORM EA. 200 FT
ENERGY FEE
WATER HEATER WIVENT/ELECTR
GRADING FEE
WATER SYSTEMaREATING
SOILS FEE
V CE
NEW R SQ. pT.
PAID
Dale
Rettiptrt
Issued prior to plan chpck carnalptirn
TOTAL
an
MING U�MT 00 IVP.R'I�;dIB
IP6W'A.ATION FAN (SINGLE RESID)
BOILER- COMP (3HP OkCOMP (3HP O
BOILER -COMP (OVER 100,009 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL
OFFICE
HOUSING MITIGATION FEE
PAID --
Date Receipt#
kio)V:\@
ISSUANCE DATE
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