29846 (2)r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
F
BUILDING DIVISION
APPLICATION/PERMIT
IDENTIFICATION
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I am lima ssm under pmviklons of Chapter 9 (commencing
�6 with Section Mao cf Division 3 arthe Business and Professions Code, and my license is
W F- in full force and IT c
a U V Licca. la. Lic.
6a IIIDale Comracnor
ARCHITECTS DECLARATION
Z p y Z I understand my plans shall be used as public records
OZ—O
F .�'. f' W Licensed R likssimal
-if bit OWNER -BUILDER DECLARATION
9 C Q 1 hereby affirm Thal I am exempt from the Contractor's License Law for the
pj 1 w < following rcamn. (Section ](111.5, Business and Professions Cwle: Any city or county
F- y O y ashich matures n permit m common, since, improve, demolish, or repair any structure5profto its issuance, .1veneyuirex theopplicam for such pemrh m file a signed muccent
;!�} that he is licensed pursuant m Me provisions of the Contractor, License w(Chapter 9
W00 (commencing with Section 7000) of Division 3 of the Business ad Professionx Code) or
L d c C Had he is exempt nhertfmm end the basis for the alleged exemption. Any violation of
Section)o3IS by snyspplicant forepermit sabjNctsnha sppliwm losoivil penulryof
FZY armanothsn IIvichundreddoll.[,($500)).
_ ❑ 1, as owner of the properly, or my employees with wages as their sole compensation.
[- will do the work, and the smcmre is not intended or offered for side(SceJBW, Business
a,3 m and Professions Csde: The Contractors License Law does not apply to an owner of
property who builds or no, ve, Iherean, and who rise, sock wink himself or through
his awn employees, provided that such improvements arc not intended or offered for
sale. if, however, be building or improvement i, sold within one year on completion,r-
the
o
-builder will have the human of proving than he did not build or improve for paproa sale.).
❑ 1, us owner of the property, am exclusively comma ting with licensed contractors to
ansuuct the project (Sec. 7t . Business and Professions Cade:) The Contractors Li-
cense law does not apply to an owner of pmpeny who builds or improves chances, and QTY,
who contracts for such projects with a contractor(s) licensed pursuant in the Ciminero",
License Law.
1 am exempt under Sec. . B & P C for this mann
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under Comby of le jury one of Ne following Warkeetiom:
❑ I have and will maintain eCenificam of Gemmae Code, sure for Workers Compen-
workf as provided for mi genion 3100 of the Labor Code, he, the perfamluncc of the
work lin which this penin is towed.
yM 1 have and will common Worker's Compcnsaion Insurance, as requite by Section
3]00 of the Lahr Code for the performance of the work for which this permit is issued.
My xom�e C uo rand Policy numne. arc:
Cartier: e K h- �10. r \Zb� Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not d completed if the permit is Acme,, hundred doila , (SIM)
tor Its,.)
I certify that in the performance of rhe work for which this permit is issued, I shall
not employ any person in any manner so as to become subject no the Workers' Compen-
O Z sec tion laws of California. Data
2 Applicant
rpt NOTICE TO APPLICANT: IL after making this Cedilicme of Exemption, you should
7 become subject to the Worker's Compensation Wovixions of the Lahr Code, you must
foMwids comply with such provisions m this permit shall be deemd revoked.
0. A
U z CONSTRUCTIONitaexaecLENDING
om NGAGENCY
V k for by wheffirm thauMmisaed(Seeti097,gency fm the performance of
U Le work for which this permit is issued (sec. 3091. Co,civ. C.)
U Loodcrs Name
Lender's Address
Fy 1certify
oc1have mad Thirty adcountrodstemrear the statelwsoctinn is
In corrtn. 1 agree to comply wenn all cit and county omtives of and stem laws r upon
a QTY.
U sZ abovengcaionediropert horcnyauNonxnuses. rives of this city menet uqm the
above-mentioncJ properly for in pection Purposes.
(We) agree to am, indemnify and keep hamdoss rhe City ol'Cupertino aguirc
iliniex,judgments. costs and expenses which may in any way same against said City
in con ice of the granting of this permit.
APPLICAc NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant c r forum building occupant gore or handle harsomm, maenad
as defind by the Cupertino Municipal Code. Chapter 9.12, and the Ifealth and Safety
Code. Section 3532m)?
❑Yes ❑No
1 Will the applicant m future boiling occupant ux equipment -1 &,air, which
Amin hakendaus dr construction, ss def ted by she Bay Area Air Quality Management
DIkmrI?
(2 Yes L3 No
1 have send the haurdnus mamnalk requipements under Chapter 6.95 of the Cali-
fomin Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the
boiling does not currently haven tenant, that it is my responsibility of notify the occupant
of the nquiremenu which must he met poor to issuance of a Cenificam of Oma,macy.
Owner or amhonsd agent Data
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT0200AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTI'/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR
PERMIT
ALTER
DRAINS - FLOOR F. AREA,
FIXTURES -PER'- AP
GAS -EA. SYSTEM- N O
GAS- F.A. SYSTHIM-OVER 0 :A
FEE
JOB DESCRIPTION
29846
.NITARY NO.
APPLICATION SUBMITTAL DAT
❑ KITCHENREMODEL
ITION
PL
J •crq(o
NIC
❑STRUCTURAL
CONTROL#
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
BUILDING PERMIT INFO
BLDG
BLEc-r PLUMB MECH
JOB DESCRIPTION
RESIDENTIAL
WL
❑ KITCHENREMODEL
ITION
❑PLUMBIPLUMBING RI: -PIPE
MULTI -UNIT
❑STRUCTURAL
,
. r+
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
GREASE TRAP
SEWER -SANITARY-STORM EA. 200 Ff.
WATER HEATER W/VENT/F,LECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENT IAL PLMB. SQ. FE
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I RAX) CFM)
AIR HANDLING UNIT (OVER 10.008 CFM)
EXHAUS'1'HOOD(W/DUCT))
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER IMAX)) BTU)
VENTILATION PAN (SINGLE RFSID)
BOILER -COMP TRIP OR 100,000 BTU)
BOILER -COMP (OVER 100.tXg)) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Ff.
OFFICE
BUILDING DIVISION ETES
PLANCHECK FEE V
ENERGY FEE
GRADING FEE
(sl II Y UI Daeif CIr
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dane Receipt#
ISSUED
DATE
COMMERCIAL -
❑ NEW BLDG/ADDITION El DEMOLITION
ID TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ Ff.
MQ FT. FLO AREA $/SQ FT.
V
r!�^ /Iy�] L6s
.� sill
Je
,
. r+
FEE
VALUATION
S G a. at's-
STORIES TYPP.CONSTRUCTION
GREASE TRAP
SEWER -SANITARY-STORM EA. 200 Ff.
WATER HEATER W/VENT/F,LECTR
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENT IAL PLMB. SQ. FE
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I RAX) CFM)
AIR HANDLING UNIT (OVER 10.008 CFM)
EXHAUS'1'HOOD(W/DUCT))
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER IMAX)) BTU)
VENTILATION PAN (SINGLE RFSID)
BOILER -COMP TRIP OR 100,000 BTU)
BOILER -COMP (OVER 100.tXg)) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Ff.
OFFICE
BUILDING DIVISION ETES
PLANCHECK FEE V
ENERGY FEE
GRADING FEE
(sl II Y UI Daeif CIr
BUILDING FEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dane Receipt#
ISSUED
DATE
i
FILE No. 907 04/17 '97 0706 ID;STORIi SALES
POOTTIIIG CARD NCAO TONT Of BUILDING
CITV OF CI IPFRTI NO
IIIIILINNC DI\9NI6N
UUILC,INGAUDH1i>f:
408 565 9820
PAGE 2
rr ......... 29845
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ROILDING IMVOKIAN'I:
OCCU PANUY UP BUILDING IS IT IER 1ITTED PLEASE READ RF.VKRSE SIDG RF.FURt
UNTIL BUILDING PINAI. IS SUINRD BY BUILDING CALLING FUK F'INAI. INSPECTION!!
INSPECTOR.
APPLICANT'S POSTING COPY
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❑
BUILDING PERMITINPA
NSPEMIONS
DATE INSPKC.
_It,m<:dull V-. r:m N. npinL';Nn(1-0:11l__.
INSI'L01ON RECORD
RUYI I n'r r}anN MLls r,
JOB rlFv'RIWI'If)N
FOUNUAIIONIFILKSl1 LD.5.
UFER(1KOUND
NOTE: ALL GRADING AND LINAINAf1F.
SHALL BE INSTALLED TO COMPLY WITH
THE APPROVED PLANS AND CITY OP
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VISUAI.PINIALONLY C'I:R'1'IBICAll f1F 0f'('1TAN('YA
ROILDING IMVOKIAN'I:
OCCU PANUY UP BUILDING IS IT IER 1ITTED PLEASE READ RF.VKRSE SIDG RF.FURt
UNTIL BUILDING PINAI. IS SUINRD BY BUILDING CALLING FUK F'INAI. INSPECTION!!
INSPECTOR.
APPLICANT'S POSTING COPY
9-