S 0953 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFurrINO BUILDING-F,LECI RICAL Pr; HT NO
BUILDING DIVISION APPLICA'I'ION/1'ERMIT PLUMBING-n1PIGUANICAL 0953
N1111 i PR"fitc, Inlr T'IFICATION
ii
❑ Consultant Fees Paid by Applicant (Initial)
I.ICENSED CONI'RACIIIRS UECLAKAI ION QTY
1 hereby affirm that 1 on licensed ander pais....... of Chapter 9 fenmtnencing
DaZ with Section 71"BoftNisionlofthe Business and Professions Csde. and my licenm is
OW Oa
in full force andf
amu I.iaenaeCl . �' o Iden 3 �/d 1G/
N Z W Dale, in PQ
ARCHHEC'1'S DECLARATION
F- N Z_ I understand my plans shall be used as public recmdv
OZ O
<kifZ. LL] hiccn,wd Pralesnonul
Ww= OWNr;R-BUILDER DECLARATION
CCG I hereby of nal that 1 am exempt from the Contractor's License Law for the
X 3 d U following reason, (Section 70315, Bmiruv, and Profc,iona Code: Any city or county
kc 4 N which requires n permit to conrtmct, alter, improve, demolish, or repair any ammure
F�Oa prior to its issuance, also requires the applicant for such permit to file a signed statement
icy that he is licensed puromntm the provisiumof tire Contractor, Licenw Law (Chapter 9
WCpO (commencing with Section 70818 of Dix ision3 of the lousiness and Prefeulons Code)or
C. a c C Nat he is exempt therefrom and the basis far the alleged exemption. Any violation of
4' Station 7031.5 by any epplirdm f r ormit-cubjccfr Ne applicant to a civil (knn11Y of
1.-, r } not more than five hundred dollars ($500L
fSp ❑1. as owner of the property. or my employees with wages as their ole ctmpcnsation.
F+ will do the work and the structure is not Intended or offered for sale (Sec. 73,14,13usmoss
Wan and Professions Gde: The Commmor.s License Law does not apply to an owner of
a 3 property whe builds or improves hereon, and whe does such work himself or through
his own employees, provided that .such improvements are not intended or offered for
sale. If, however, the huilding m improvement is sold within one year of eoniplefer, the
ner-builder will have the burden of proving that he did not build or improve for put -
'o, if.cled.
1, as owner of propi am exclusively comments with licensed commcnns to
resumer the project (Sec. 70,C1. Business and Professions Cede.) The Commctoe%Li
-
c rise Law docs not apply to an owner of property who builds or improves durcurt ned QTY.
who contracts for such protean with u contractors) licensed pursuant to the Commcteis
Lironse Law.
I am exempt under Sec. .B& P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declardmns:
❑ 1 have and will maintain a Certificate u1 Consent to sell -insure for Worker's Compen-
sation, as provided for by Section 37M of the Lobar Cade, for the perlonl ante of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of dltc work for which this perout is issued.
My worker>, Cumpc attars Inc d Policy number am:
C esa,/o'.d .'e%c. roue, No.: ,,{�/•L3/970 ffL
CERTI EVE TION FROM WORKERS'
COMPENSATION INSURANCE
Ilhis section need not be completed ifthe permit is forone hundml dollar,(SIM)
in l
1 unify that in the peHorrunce of the work for which this permit is issued, I shall
nal collect, any person in any manner sr, as ria become subject to me Workers' Compcn-
O Z .mien laws of Califnmia. Date
Z O Applicant
NOTICE "10 APPLICANT. IL after making this Cendiume of Exemption, you should
a, hcmme mbjw ,,,he Workers Cma,cnsation pmvisinns onhe Labor Coda you most
FL1 forthwith comply wire such provisions or this pemdixtell he deemed Invoked.
Q
U 0 tl CON he. is. IONLENDINGAGENCV
UP Ihit,,hib,hithat
.iti istted(eturner0 lendingagency for the performance of
� P the work fila whicti this pernid is :sated (Sec. 3097. Civ. CJ
O U Under's Nome
} [17 Lender's Address
1 cerlify that 1 have read his upplictnon and store that the uMve information is
F" y correct. l agree to comply with all city and county ordinances and nate laws refining to QTY.
U Z building construction, and hereby andurim representatives of this city vo enter upfrathe
above -meat toned or fior inspection purposes.
(We) agru as save, indemnify and keep hurmlesa the City of Cupeni no against
liabilities, judgment, costs and expenses which may in any, acerae against said Cil,
in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND P .1 XONPbY W LTH ALL NON -POINT
UA7ARD US ATE RIALS DISCLOSURE
tll the applicant or fuse a he ding occupant v ere or handle fir, anon material
as def 'd by the Cupertino Mun 1 Cade. Chapter 9.12. and the Health and Safely
Cade, Section 25532(1)7
EJ yes Cl No
Will the appi icunt nr Imum he ildi ng accepted use equipment or devices which
emit Intruders air contaminants as defined by the Bay Arca Air Qnul ity Management
Dislncl?
❑Yes [I No
I have read the havofdous materials requirements under Chapter 695 of the Cali.
f num Health & Safely Gde. Sections 25505. 25533 and 25531. 1 undenland that if the
building• does ern common, M1ave a tenant that it is my m ...... bility m notify the n vu,sen
of the requirements which must W art prior to issuance of a Cenificam of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
OVER IBMAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITBAISC.
TEMP. SEEDER OR POLE [NST
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLETS -SWITCHES_ ITS I
SQ F I'.
iff: J
RSQyj TflfYR AREA SISQ. FT.
PLUMBING IT FEE
ID
I
PERMIT ISSUANCE L;1
BUILDING PERMIT INFO
VALUATION
BLDG lil.li PLUM MECH
re 77
DRAINS- FLOOR. ROOF. AREA.O
STORIES
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KI'TCIIEN REMODHI
ADDITION ❑ PLUMBING RE PIPH
❑MULTI -UNIT [D STRUCTURAL
MODIFICATION
F1 INTERIOR ❑CHIMNEY REPAIR
IMPROVE: MIvYT SWIMMING POOLS
❑BATH REMODF EI'All ❑DEMOI.II'ION
❑OTHEk
GAS -IiA. SVS1 ElibI INC. I OUTLE'I:S
OCC. CROUP
'
GAS -IiA. SYS1 EM -OVER i (FA)
GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAY
PLANCHECK FEE
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
[10 1 HER
ENERGY PER
WATER HEATER WNENTIELECfR
GRADING TH
RSQyj TflfYR AREA SISQ. FT.
PLUMBING IT FEE
FEB 10 ANS`D
ry Oh t,urcnl Jill
PERMIT ISSUANCE L;1
ALTER -DRAIN& ;N '1' (E I
VALUATION
BACK FLOW PROTECT. DE
DRAINS- FLOOR. ROOF. AREA.O
STORIES
"1'YPEC(
FIXTURES - PER TRAP
GAS -IiA. SVS1 ElibI INC. I OUTLE'I:S
OCC. CROUP
'
GAS -IiA. SYS1 EM -OVER i (FA)
GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAY
PLANCHECK FEE
SEWER -SANITARY - STORM EA. 200 Fr.
ENERGY PER
WATER HEATER WNENTIELECfR
GRADING TH
WATER SYSTEMGnEA'I'ING
SOIIS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
Date ccipt p
TOTAL:
TOTAL:
BUILDING FEB
MECHANICAL PERMIT FEF-
SEISMIC FEE
ELECfRI '[E
PERMIT ISSUANCF,
ALTER OR ADD FO MECH.
PLUMR `G FEE
AIR HANDLING UNIT (1010.0i
MECHANICAL 'T
AIR HANDLING UNIT (OVER IB,(KKICFM)
CONSTRUC'HON'IX
EXHAUST HUGE) OWDUCT)
HOUMNGMITIGATI( FEF.
HEATING UNIT (TO H lo.coo II'ru)
HEATING UNIT (OVER 100.000 BTU)
PAID
VEb IULAT10N FAN (SINGLE RESIDE
Dere Receipt n
BOILER-COMP(31HPOR IB0.M0BTU)
romG,
BOILER-COMP(OVER 100,00013TU)
AIR CONDITIONER
ISSUANCE DACE
1-1
NEW RESIDENTIAL MECH. SQ. IT.
ISSUED BYRY:
OFFICE