99120064 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTCAL PERhlll' NO.
RI
BUILDING DIVISION APPLICATION/1'ERMIT PLUM nwc-nn!r,Ilnnlcnl.
BIIILOINI: 1'RO.II?4."I' IDENTIFvsMe
ICATION _
/;A
❑ Consultant Fecs Paid by
LICENSED CON "I RAC 'DOR 'S DECLARATION
I Herrn, affirm Ilial I am hCansal made, provision, of Chapter 9 Icsrmmmcing
Flye in full foreeanJeff es
_
QUV hiccnse Class Lic.p
N Q Dae �-�-�z-� Conlraclnr
ARGIII ECTS DECLARATION
~ o, Z I understand my plans shall he used as public records
O- 14
H F W Licensed Professional
OWNER -BUILDER DECIARNHON
C Q 1 hereby air.. Gat 1 am exempt from the Contractor's License Law for the
X6 U following reason. (Section 9031.5. Business and Professions Curie: Any city or county
W 3 4 y which requires a permit no construct, alter, improve, demolish. or repair any structure
prior it, issuance, also trquires the upplicunf fur such prnnirto file u signed statement
Eby That he is licensed purmant ,,,he poviaons of the Cent ... nr's License Luw(Chapter Y
WaCl (commencing with Section 70X1) of Division 3 offhc Business and Professions Code) or
6 6 p C that he is exempt therefrom th
and the basis for e alleged exemption, Any violation of
W I ySection 7031,5 by any applicant for a prorut subjats the applicant to a Civil penally of
not more than five hundred dollars ($500).
0 D I, us owner, of IIIc pmpcnY• ,, at, employees with wages as their sale compensation,
p, will do the work. inerthe structure is Hol intended or offered for sale (Sec9fW. Business
Wad and Professions Cade: 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 employees, Provided that such impmvemun¢ are not intended or offered for
sale. If. however, fbe building or itnprovemenl is sold within one year of completion. the
was W ilder will have the burden of moving that he did not build or improve for In' -
poor of ear.),
I, as owner of the property, :nn exclusively cnnlmcting with licensed comforters m
navnc'I the pntjucl (Sec. 7044. Business mal Prelesninnn Code) This Contractors U-
se Law does nm apply to an owner of porymy who builds or improves thereon, and QTY.
who contracts for such projects wish a cantmnnKs) licensed pursuant to the Contractors
License Law.
[] I um exempt under See. .B& P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby oflinn under penalty of perjury one of the following declarations:
I hove and will nminmin u Ccrfilicute ofCnnaem to self-insum [tar Worker's Compen-
,.it I, as provided ha by Salion 3700,11 the Labor Ctde, for the perlbmmnec of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Station
170toOhe LIII-rCocaffor thifiverfermancroA work for which this permit is issued.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENT'IN.
PANELS
UP PO 200AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT IMISC.
TEMP. METER OR POLE I
POWER DEVICE -S
SWIMMING POOL ELEC'
OITILETS-SWITCHEL
— CERTIFICATE OF EX&IMPTION FROM WORKERS'
COMPENSATION INSURANCE
(chis seclinn need not he tttmplmed if the pemenl is forme hundred doilat-($1001
or Ices.)
irtail,lian
Per in the any manner 'It the work for which this permit d Issu Con d. swan'
not employ any person in any manner ut as m become mA3at to the Wnrkos' Compem
Z often Laws of Califunar Dan:
O Apphcml 1
7 NOIICE TO APPLICANT: It, after making Ills Cenihetnc mf Exemption. You should
a7 heroine suhjccf to the Worker's Compensminn prmewma of the Labor Cattle.You must
f�forthwith comply with. such provisions or this permildealiW deemed revoked.
4'0
CONSTRUCTION LENDING AGENCY
Up 1Nathyal'lirat that there ism consumer on leadi ng agency for the performance or
IL.- the work far which this permit is issued(Sec 3097, Civ. C.)
0U lenders Name
U lenders Address
W I eenify that 1 have rcud this application and sloe lhat 0e above information Is
Cis
i..t V) annm. I agree to cmnplY with all city i it county u dinnncu unit stain lows re'unne to QTY
U Z building csmmmnlon. and hereby anrwnderu,,m nrmivewf this city to infer upon Thr
ut ave"meanoned property for inspection purposes,
(We) agra to sa, indemnify and keep harmless the City of Cupertino against
labdltie,judgmmrp, coax ural cx,nun which may m any way same against mid City
in onsequcnac ml the gromin, of This pcnnit.
APPLICANT UNDI]Y'TANDS AND '1.'OMPLY WITH ALL NON -POINT
..a....._._... _„
HAZARDOUS MATERIALS
din, ex ALS DISCLOSURE
in fortune Wilding e, Chaptscoreor handle Heal( and Sated
us JdineJ by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Come, Sectio 25532(u).'
❑Yes ❑No
Will the applicant or fmure Wilding oocuponl use cysynnal or devices which
emit haamdous air contaminants as defined by the Ray Arca Air Quality Management
Hisvict'!
C] yes No
1 have read be haruNous mmerials requimmcros under Chapter 4.95 of de, Cali-
fnmia Health & Sufcty, n, Suctions 25505. 25533 and 25534. 1 understand that if the
hoildlna Jucsnolc ntly Luvealcnum stay resrynlsibilhy to notify the oaupmn
the
NEW RESIDENTIAL
PLUMBING PERMIT I FEE
PERMIT ISSUANCE
ACT FR - DRAIN & VENT - WRIER 1 :
BACK FLOW PRI,HECT. DEVICI:
DRAINS - 1,R ARBA. COND,
FIX'HURLS - PER TRAP
GAS - EA. SYSTEM -I INC. 4 Ol
TAS-F.A.SYSTE -OVER4(EA)
GR17ASMNDUSIRF WASTEINTERCEITO
GREASETRAP
SEWER - SANI'T'ARY - STORM IiA, 201 FI'.
WATER HEATER WNENDE ECfR
WATER SYSTI;Mn REATING
WATER SERVICE
NEW RESIDENT JAL PLMB. SQ, FT.
rOTALI
MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ACIER OR ADD'10 MEC".
AIR IIANULING UNIT (TO 10,000 CFNU
AIR HANDLING UNIT (OVER 10.000 CFM)
HXIIAUS'I HOODIWIDUCO
HEATING UNIT ITU IIXLIMM111'1'U)
HEATING UNIT (OVER 10(1,1101 BTU)
V fl N'1'RATION FAN (SINGLE RESID)
BOILER - COMP PHP OR 1110.(X10 BTU(
MOILER - COMP(OVER 100,1100 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MEGA. SQ. FT
OFFICE
$ISQ. IT.
00
5.11: Alul /
BUILDING DIVISION TEES
PLANCHECK IEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dat, Receipt N
Int /,�\ r
iU1LDING FEE �S U
S
MI, E --IC
'LECfItIC FEE
PLUMBING FEE L.
ML-EHANICAL FFGF:_---�_�
CONSTRUCTION TAX
HOUSING Nil I1GA'HPON THE
PAID
Here Rcceim 11
12 I �- /
/C
LINO `
P
C
CON'I'ROI,a
�w
(Initial)
UILDING PERMIT INFO
ELECT' PLUUMBBMECH
❑ ❑
t�7
FEE
JOB DESCRIPTION
RESIDENTIAL
ITCHEN REMODE
❑ SFDW-❑,.3� KL.
KI�
❑ADDITION I4PLUMBING RE PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
C3 INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATA REMODEIIRICI'AIR DEMOLITION
QOTHFR
❑DEMOLITIONF1 ❑FOOD SERVICH
eTTS
'imp VhMENT
PLUMBING PERMIT I FEE
PERMIT ISSUANCE
ACT FR - DRAIN & VENT - WRIER 1 :
BACK FLOW PRI,HECT. DEVICI:
DRAINS - 1,R ARBA. COND,
FIX'HURLS - PER TRAP
GAS - EA. SYSTEM -I INC. 4 Ol
TAS-F.A.SYSTE -OVER4(EA)
GR17ASMNDUSIRF WASTEINTERCEITO
GREASETRAP
SEWER - SANI'T'ARY - STORM IiA, 201 FI'.
WATER HEATER WNENDE ECfR
WATER SYSTI;Mn REATING
WATER SERVICE
NEW RESIDENT JAL PLMB. SQ, FT.
rOTALI
MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ACIER OR ADD'10 MEC".
AIR IIANULING UNIT (TO 10,000 CFNU
AIR HANDLING UNIT (OVER 10.000 CFM)
HXIIAUS'I HOODIWIDUCO
HEATING UNIT ITU IIXLIMM111'1'U)
HEATING UNIT (OVER 10(1,1101 BTU)
V fl N'1'RATION FAN (SINGLE RESID)
BOILER - COMP PHP OR 1110.(X10 BTU(
MOILER - COMP(OVER 100,1100 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MEGA. SQ. FT
OFFICE
$ISQ. IT.
00
5.11: Alul /
BUILDING DIVISION TEES
PLANCHECK IEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dat, Receipt N
Int /,�\ r
iU1LDING FEE �S U
S
MI, E --IC
'LECfItIC FEE
PLUMBING FEE L.
ML-EHANICAL FFGF:_---�_�
CONSTRUCTION TAX
HOUSING Nil I1GA'HPON THE
PAID
Here Rcceim 11