S 0955 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.DINC. - ELF,C I RICA PERM rr NO.
BUILDING DIVISION APPLICATIONIPERMIT PLT; PROJECT IDDANI(LM. S 0955
BIIILDIN'1]PHOJECT IUENTIPICAT'ION
aP
(PA
/ Lq7J (^ /f� ❑ Consultant Fees Paid by Applicant (Initial)
C'ONTRA�CTOR'S DECLARATION !� Y QTY ELECTRIC PERMIT
I hereby affirm that I am licemeal under provisions of Chanter 9 Bonamendng
DMZ with Section 700n) of Division Jafthe limina and Professions Code, and ray license is
�Id. in lull force and effect.
ULiccnsc Class Lich
NZQG IJWe CanVnrYnr
ARCHI'1'ECI"S DECLARATION
~4Z OI modcomidmy plansshill be used .,public memo,
Z -M
H W licensed Professional
OWNCRIBUILDER DECLARATION
C Q I hereby affirm that 1 am exempt from the Contractor's License law for the
O IL U following recon. (Section 7031.5, Business and Professions Code: Any city ser county
LL O m which requires a Permit to construct alter. improve, demolish, or repair any wudurt
G prior to its issuance. also requires the applicant for such Fermil m file a signed statement
to Ohio hcislicensed purs..,le hepraxisiod,af,mConlmctne,Liccnsclaw(Chapter9
alp �0 [commencing with Section Ton) Of Division Jof,he Business and Professions Crdc) or
p� o p� That he is exempt Ili onto) and Thu basis for the alleged exonmw
tion Any vioeon of
W y w Seerm 1 ]8315 by any Applicant far a, lana ,ubjccu the appllcunl w u civil Penalty of
not mom thin five hundrecldullan 1$510).
S 0 D I, us owner of the properly, ov Ary employees with wages as their.aolc comply s dam.
F, will do the work,andthestiumurc is not intended meWrcJ forsrlc(Ses.]Dl4. Business
W 3 m and Ptofeasions Cole: The Cmanw n's License law does not apply to an (owner of
property who builds or impmven thereon, and who does such work himself or through
his own employees. provided that such improvements are not intended or offered far
sale. If, however, the building nr improvement is sold within one year of completion, the
owner -builder will have the hmJeA of proving that he did not build or improve for puts
poo, If side.),
❑ 1, as owner of the pmperty, am extlmively contracting with licensed aommeans it,
ms,met the pr%ect (see. ](FW. Bastin... and PrOmW ons Codc') TLB Conaannrs Li-
al.aw does not apply lot nn owne'of property who builds or improves thereon. and QTY.
who romme x for such pit Jec„witll a canaaetor(,) licensed pursuant to the Camruemrs
license law.
rl I en exempt under Sec . B & 1' C for this mason
• Owner Dam s:
t WORKER'S COM PENSNHON DECLARATION
I hand w it maj under penalty lOF mperjury one of the following Wdamtaln
❑ I have and will maintain Section
3700 of Consent ,Coks. fare for Worker's Compen-
sation, as provided for by Seninn J]IX) of the lahor Cade, far the perfonnnnce of the
work far which this permit is issued.
❑ 1 have and will maintain Worker, Compensation Insurance os rectorial by Section
3704 of he Labor Code, for the pcdonnanse of the work for which this panni, is Issued.
MyWnrker nmpRAsa�t1 In cc curVrJcrund Policy mdve r
Carrier:7M7/ Policy No.:
COMPENSATION INSURANCE
(This section need not he completed if the Permit is Income hundred dollars (SIM)
or Icss.)
ork
ch
f� Toy any that in the Iterany nowarm, so of the
become
for subject 1.'he Wot is rkers
d, I hall
Clniam-
nnt employ any person in any manner sit us m became mbjen m the Wnrlen' Compen-
�Zcation Law, of Celifomla. Dee
z O Applicant
NO[ [CH 10 APPLICANT: IL after...akin, this Cenificme of ExemPtion you should
i F N Mcome subject to the Workcrs Contpmssminn pros ons of the Laden Close , you must
a ^, tnnhwith emnply with such pit ision,ser this peter;, shall be deemed revoked.
J Ca
CONS them UL"UUN LENDING ngagerAGENCY
V � Ihcrehy rffinn thnnMrcisu conservation lending agency for the pertnnnance til
E. F the work far which this permit is issued (Sec. 3097. Civ. C.)
O V lender's Name
} lenders Addrtss
U
Ul 1 ccnify Ron I have read this application and one that the above information is
FN career. l agreom comply with all city and county ordinances and state law, relating to
m
U Z building construction, and hereby authnrim representatives of this city In enter upon the
ubswcanemloned p d,0y fill impenian Purryrws.
We move to save, indemnify and keep harmless the City of Cupertino against
Ilabilides, judgments, costs and expenses which may in any way recall against said City
in onsc.uvncc of that ernmin, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI 111 AL1. NON -POINT
SOURCE RE ;ULATION.`
gigaat en App ¢wWContmemr Irate
HAYAHIR)US MATERIALS DISCLOSURE
If the applicant or future building occupant store or handle hrowdoas material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Coda Section 25532(r)P
❑re, 0 N
Will the applicant ser )inure bull,]; rig occuPom use cquipnant or devices which
call[ hmurdm
ous air conminants ;is defined he the Bay Area Air Quality Munagemcm
Donieto
Yes ❑ No
PERMITISSUANCE
APPLIANCUS-RU91DENI AL
PANELS
INTO 20OAMPS
OVER Into AMPS �
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. M, HE OR POLI; INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ lel'.
PLUMBING PERMIT
Plo RMI F ISS DANCE
ALTER - DRAIN & VENT- WATER (ESA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF AREA. GOND,
IIX'LURES -PERTRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS -HA SYS'I'13M-OV HR 4 HFA)
GREASIVINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SAN ITARY - STORM EA. 288 Ff.
WATER IIFATHR WNENT/ELECTR
WATER SYSTE ffREATING
WN'Iili SERVICE
NEW RISIDIiN'TIALI'hMB, SQ. PT.
T(TI'N.
QTY. MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD 10 MECH.
AIR HANDLING UNIT (TO 1(1,00 CPM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (WIDUCI)
HIII 'INC, UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 1 W.gID BTU)
VENTILA'DON PAN (SINGLE RES IDo
1101LER -COMP OHP OR I, ,j Ii'IV)
BOILIiR- COMP (OVER I(XMXX)11'1'U)
Il-
BUILDING PERMI'I'INFO
_ RLDG ELECT PLUMB MECII
❑ 'c--^ ❑ ❑
FEE JOB DESCRIPTION
eDENTIAI:
WL ❑ KITCHI?N REMODEL
[]ADDITION [D PLUMBING Rli-PIPE
❑MUTAI UNIT [:IS'IRUCHJRAI.
MODIFICATION
WI❑ 'I'IIRI(]R ❑CIIIMNIiV RIiI'NR
I'ROVCMENT ❑SWIMMINGPOOLS
BATH RIiMODELREPAIR ❑ DEMOLITION
COMMERCIAL
El NEW BI.DG/AUDITION ❑DEMOLI'T'ION
❑THNAN]1 01rOOD SERVICE
IMPROVEMEN
❑D'I'VER
SQ. FE FLOOR AREA SISQ, FT.
PAI®
FEE AfOII 7 DrA
1NU
_ BUILDING UPIISION FRIES
PLANCHECK FEE
ENERGY FEE
GRADING FEB:
SOILS FIRE
PAID
Ilam 8
)PAS.:
RUILDINGF
FEE SEISMIC ITE
ELECIRICITE
PIA -Pit FEE
MSCI IANICAI. FEE
CONS I'RUCHON TAX
HOUSING MITIGATIO FEE
PAID
Due ReaiF, a
AIR CONDITIONER i I
1 have read are harsdous m ,m,, requinmcn,s muter Chapter 6.95 ul the Cull-
fnmia Health & Safety Code. Sections 25505.25533 and 25531.1 umlcnmnd,bat Bthe NEW RESIDENTIAL MECH. SQ, IT.
building div not currently have a tenant that it is my msponsibility to notify the occupant
(of the "arement- which muf, be met poor to issuance of a Cenifiedm of f scup day.
ITTPAL
Owner or midamcd.gent
Dim '
OFFICE