99100146APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
RTINO
RUIL )ING- ELECTRICAL
❑ 57-�
I PERMIT
ISION
APPLICATIONIPERMIT
PLUMBING - MECHANICAL
O KITCHEN REMODEL
❑PLUMBING RE -PIPE
0STRUCI'URAL
5000 1
APPLIANCES -RESIDENTIAL
BUILDING PROJECTADEN
El'WILOINGAIDDRESS.,
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SANITARY NO.
APPI.ICAI'ION SUBMITTAL DAO
5
SIGNS ELECTRICAL
GAe
2N
f�
COMMF,RCIALI
ONEWBLDG/ADDITION
611"
PHONE:
C< NTRACTOR'S N E:
T N AL#4 C-203
Rmr
N/C
❑
CONTROL p \
CHRECf/IiNGINEER: LIC NO:
A RE �Mc' / � ^K A��/
',1 P_`' /J 'Y{
rnraTnrry
PHONII:
I F RI
BUILDING PERMIT INFO
❑ Consullanl Pees Paid by Applicenl (Initial)
1 humhy affnn Inas 1 am li¢ascd under provisions of Chapter 9 t3ommencing
WO, with Seen.. 700 )nf Division 3.fthe Business and Professions CIAc,a dmy license is
FI -r in full Luce Imd
�UU License _ `�4 ssLic.p
N f Imposemr
FG =y ACIII'EC'fS DF.CLAR ON
Z O7�. 1 undemtaod my plans shell he used as public records
OZEZ
F on F; Licensed Professional
,..I OWNER -BUILDER DECLARATION
W�fxy f� IWyI 6 I hereby affirm that I am exempl from the Cnntnmor's License law for the
W a 6 F follow'mg reason. (Suction 7031.5, Holmes, and Professions Gxlc: Any city or county
6Fl O ya which requires a permit to construct. alter, improve, demolish, or repair any structure
rA ri prior m its issuance,.Iso mluires the applicant for such Fri to file a signed statement
That he is licensed pursuant to the Provisions of the Contractor's License Law lCha111119
p(commencing with Section 7000) of Division 3 of the Business and Professions Crane) or
d Not he I,exempl therefrom ad the basis for the alleged exemption. Any violation
MSection 7031.5 by any applicant for a permil subjects the applicant m a civil penally
Spnot mare in.,, livehund.1 dollars ($501).
❑ I, as owner of the property, or my employees with wages as their sole rompcnmti
F+ will do t he work. and the structure is not i mended or offered for sale (See. of j
0. 3 m ani Pmfessions Ca)e: The Cnntrunore License taw does not apply to an ownpmpenyhis wn emplyees, provided that such imprwmamus am not intended or offensell If. however. the building or improvement is sold within one year of completioncaner-huiWer will have the burden of proving that he did not build or improve for'we of sall')
I, as owner of the properly, mo exclusively contracting wird licensed contract(,
construct the project (Sec. TW, Business and Professions Cale:) TTe Cantraecense Law does not apply Io an owner of properly who builds or improves thereon
who contracts fonuch projects with a conmactor(s) licensed pursuant to the Contractors
License law.
1 am exempt under Sec. . B & P C for this reason
lomar Date
WORKER'S COMPENSATION DECLARATION
1 hcrchy I... , under penally of pc,I., one of the following deel,colu ns:
on, as and will for by
a Cion 37 a of the Labor
Cocensule Rn Workers Ce of the
colon, m' hick hi for by is elan 391X1 of the Luhm C,da for Ne performm�a of Nc
work for which his permit is issued.
I have and will maintain Workers an a cifthew Insurance, h required by Section
371X1 of the Labor Crxle, for the performance of the work for which this permit is isxuW.
My Workers Compensation Insumntt carrier tnJ Policy numFer an:
Cartier: -Policy No:
CERTIFICATE OF EXEMPTION FROM WOkKEkS'
COMPENSATION INSURANC17
(This section need not he completed if the prnnil is (Dome bundled dollarsl$IfXI
(,r lcasJ
1 certify that in the performance of the work far which This pcndl is Issud.l xha
not employ any person in any manners .M1r�o_n-y nubjedtys farkeri Compo
O Z action Laws cf Califa la. )ate [ ( 1
77 Applicata
.7y
NO 70 70 APPLIC// LILuter ,gltnis Cerificmeof Exemption. yrs
abecome mhj¢t m Nd orkers Compensation Provisions of the Labor Code. Inumff
G lunhwith comply wird such provisions or this permit shall be deemed revnk
0
oes -0
COtthen isacTRUC m LENDINGAGENCY
V 0 Thereby uffinn that isaconxtmctinn lending agency for the Performance of
w H the walk for which this Pc ram n issued (Sec. 3BO, Civ. C.)
O L) Lender's Name
Cil Leaders Addmss
0. 1 verify that I have lead this application and state Our the shove infnu mio t is
N comet I agree to comply with all city and county ordinances and state laws relating to QTY.
U Z building construction, and hereby authorize representatives of this city to enter upon the
sat shove -mentioned pmpeny for inspection purposes.
(We) agree to xnve, indemnify and keep harmless the City of Cupertino ngains,
liabilities.judgments, mstsand eapenseswhich may in any way accrue ageinsl said City
in, Ise,pmneoof theemoting of Nix permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicam or fumm building occupant moreer handle hazardous material
defined by the Cupertino Municipal Codes Chapter 9.12, and the Health and Safety
de. Sermon 255321uyt
[:j Ye, -1 No
Will the applicant or future building arrogant use equipment or devices which
In heard... air contaminants as defined by the Bay Area Air Quality Management
,,,let?
❑Yes ON.
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali.
ria Health & Safety Cala Suctions 255115, 255331md 25534. 1 understand that if the
Tiding does not currently have�1Jhm it Ivey responsibility to notify the ceanpam
the repolregenls whirlAnjsl be no mii 1. i ... cone of a Cerifcate of Olufare,
PHRMI'I' ISSUANC17 _ I I
ALTER - DRAIN & MINT- WAI ER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF AREA. CONE).
FIXTUR&% - PER TRAP
GAS -EA. SYSTEM. I INC.4 OUTLETS
TOTAL:
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT' (TO 13,000 CFM)
AIR HANDLING UNI'[' (OVER 111.000 CFM)
EXI IAUS 'T HOOD (W/DUCT)
11HN ING UNIT TIO If0j)o) RTU)
HEATING UNIT (OVER 100. 00 BTU)
VENTILATION PAN (SINGLE RISID)
BOILER -COMP QHP OR 100,00OBTU)
BOILER - COMP (OVER 100,000 tl'rU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. ler.
TOTAL:
OFFICE
/ �D
STORI TYPI
OCC. GROUP
BUILDING DIV ISION PI
PLANCHECK FEE
ENERGY FM
GRADING FEE
SOILS FEE
PAID
Dam Receipt#
A TOT
UILDING FEF.
JTEE quisMl IP''F . %
:LECI'RIC THE
' UMIIING FEE
M.
CONSTRUCTION TAX
HOUSING MITIGATION PEE
PAID
Dare
3/SQ. PT
ISSUANCE DA"I'Ff�f�
❑ ❑
❑ 57-�
ELECPRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL
❑ SFDWL
❑ADDITION
OMULTIANII
O KITCHEN REMODEL
❑PLUMBING RE -PIPE
0STRUCI'URAL
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
MODIFICATION
UP DO 200 AMPS
0INTERIOR El CHIMNEY REPAIR
IMPROVEMENT [ISWIMMING POOLS
OBATHREMOD REPAIR ❑DEMOLITION
(H HLH y
Ce TI(•-�#y�2
t aim
201-1000AMPS 4
OVER 11WAMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TILMR. MITER OR POLE INST.
COMMF,RCIALI
ONEWBLDG/ADDITION
❑DEMOLITION
VVIC0
El TENANT
❑FOODSERVICE
1MrKOVFMF.NT
I F RI
❑ OTHER
TLEfS-SWR � -PI R
PHRMI'I' ISSUANC17 _ I I
ALTER - DRAIN & MINT- WAI ER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF AREA. CONE).
FIXTUR&% - PER TRAP
GAS -EA. SYSTEM. I INC.4 OUTLETS
TOTAL:
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT' (TO 13,000 CFM)
AIR HANDLING UNI'[' (OVER 111.000 CFM)
EXI IAUS 'T HOOD (W/DUCT)
11HN ING UNIT TIO If0j)o) RTU)
HEATING UNIT (OVER 100. 00 BTU)
VENTILATION PAN (SINGLE RISID)
BOILER -COMP QHP OR 100,00OBTU)
BOILER - COMP (OVER 100,000 tl'rU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. ler.
TOTAL:
OFFICE
/ �D
STORI TYPI
OCC. GROUP
BUILDING DIV ISION PI
PLANCHECK FEE
ENERGY FM
GRADING FEE
SOILS FEE
PAID
Dam Receipt#
A TOT
UILDING FEF.
JTEE quisMl IP''F . %
:LECI'RIC THE
' UMIIING FEE
M.
CONSTRUCTION TAX
HOUSING MITIGATION PEE
PAID
Dare
3/SQ. PT
ISSUANCE DA"I'Ff�f�