31331APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY �F CUPERTINO BUILDING ELECT PERMITNO. rA 1
BU331ILDINGDIVISION APPLICATION/PERMIT PLUMBING-MF.CHANICAI, s1
E LL l
CONTACT. PHONE:
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It J `o _ 224 —no ❑ Consultant Fees Paid by Applicant (Initial)
I hereby officer that I am licensed under provisions of Chapter 9 (commencing
RESIDENTIAL:
with Section 9000) of Division 3 rime Business and Professions Code, and my license is
C SFDWI,
in fail farce and causes.
❑ADDITION
License Class I,Ic. M
C MULTIUNIT
Dade Contractor
ARCHITECTS DECLARATION
❑INTERIOR
1 understand my plans shall be used as public records
IMPROVEMENT
Lieensnd Professional
❑ BATH REMODEUREPAIR C DEMOLITION
OWNER -BUILDER DECLARATION
1 hereby chine that 1 am exempt from the Comments's License Law lot the
following reason. (Section 9031.5, Business and Professions Code: Any city or county
which requires a Permit to construct, edeas, improve, demolish, or repair any stmeture
prier m it, i .... m r, also rcynirex me ... ]team for such permit m file a signed swtement
that he is licensed pursuant to the provisions riche Contractors License Law (Chapter 9
(commencing wide Section 91X%11 of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the bods Er the alleged exemption, Any violation of
Section 91131.5 by any applicant for a permit subjects she applicant to u civil penalty of
t more than Eve hundred dollars (SSW).
I, as owner aides, propany, or my employees with wages as their sole compensation.
will do the work, a.d the structure is not intended nr offered Iia tale (Sec 9844. Business
and Professions Cale: The Contractors License law does not spay to an owner
f
pmpeny who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building nimprovement is sold within ane yearofcompletion, the
wner-builder will have the burden of proving that he did not build or mini for pun
pose of sale.).
1, as owner of the proper, am exclusively contracting with licensed contractors m
onstruct me project (Sec. 9614, Business and Profession. Code:) The Contractor's Li-
nttLaw does not apply manowner oftmper who builds or improves thereon, and
QTY
who contracts far such pmjee ss with a contract,,,(,) licensed pursumn m the Comemenrin
License Law.
0 l am exempt under Sec. ,B&PC for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declarations:
Q I have and will maintain m Certificate of Consent to self -insure for Workers Compct-
ss)ion, as provided for by Section 3900 of me Labor Cale, for me Performance of the
w:3 fa which this pcmdt is issued.
❑ : have and will maintain Worker's Compensation Insurance, a required by Section
3900 of the Labor Cede, for the Performance of the work for which this sche ie is issued.
My Mmme'. Compemmion Insurance artier and Policy mumM, are:
Carriu : Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wermn need not Iw completed ifthe permit is bureau hundred dollars ($I00)
or fair.,
I cattify that in the performance of thu work for which this permit is towed, Isbell
we employ any person in any manner m as to become subject to she Workers Compen-
sation I/ ws of Cd fans v. Dutc
A,dca e
NOTICL TO APPLICANT: IL attar making this Certificate of Exemption, you should
become subject to the Worker's Compensation provi.sioms of the Labor Code, you must
fidhwith comply with such provisions or this permit shall Im deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is. construction Iendi ng agency for the Amber auncr mf
the work for which this permit is issued (Sec. 3097, Civ. C.)
benders Name
Lender's Address
I certify that 1 have read this application and state shat the above infonnaion is
QTY,
erect. I agree to comply with all city and county ordinances and state laws relaing m
building construction, and hereby resonant representatives at Nis city in enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costs and expenses which may in any way aceme against said City
in morin o� Teets permie.
PPLIe
APPLICA nc UNUERSTA L COMPLY WITH ALL NON -POINT
SOURCE ATIONS.
Io/23A(,
Will the applicant or future building occupant store m handle haaallous material
as defined by the Cupertino Municipal Cafe, Chapter 9.12, and Ne flmlth and Safety
Code, Saban 25532(a)?
❑Yes 1 �
Will the applicant or rutuum building occupant use equipment or devices which
mit hara dons air contaminants as defined by the Bay Arca Air Quality Management
Uistnl
❑ Yes
I have read she hounclous macrials requiremam¢ under Chapter 6.95 of the Cali-
fornia Health & Safety Code. Sections 25505. 25533 and 2151,1 understand that if me
holding dens trot curmntl ave ¢wes,t 'us myresponzihility to nmify the occupant
ofibr ear%Tnpts wnich mus a, smanceofn Ccnifcnmafnv.....
ELECTRIC PERMIT FEI
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
PANELS
�r
UP TO 2110 AMPS
SIGNS ELECTRICAL
TEMP. METER OR POLE INST
POWER DEVICES I
S WIMA14PIWOL ELECTRIC
NEW
PLUMBING PERMIT I FEE
PE
S AN 4
RMITLAN&VENT—WATER (EA)
RACK FLOW P CE DEVICE
DRAINS — FLOOR. RCC&O EA_ GOND.
GAS—EA. SYS, 1'C.J OUTLETS
GAS—EA. SYSTEM- V�4(W)
GREASETRAP
SEWER—SANITARY—STORM EA. 200 FT.
WATER HEATER W/VET/ELECTR It
WATER SYSTEM"EATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, IZ
MECHANICAL PERMIT I FEE
PERMIT ISSUANCE
R OR ADD TO MECH. a
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER Maps CFM)
F.X HAUST HOOD (W/DUCT)
HEATING UNIT ('1'0 100,003 BTU)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER —COMP (Mies OR 1M.000 BTU)
BOILER—COMP (OVER 100.000BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
10-2-%-965
❑ I ?Zs'g,
BUILDING PERMIT INFO
I BL ELECT -. PLUMB ECH /
JOB DESCRIPTION
RESIDENTIAL:
C SFDWI,
❑ KITCHEN REMODEL
❑ADDITION
11 PLUMBING RE -PIPE,
C MULTIUNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR C DEMOLITION
[]OTHER
C NEW � 1ADDITION ❑ DEMOLITION
kJq'ENANT ❑ FOOD SERVICE
MPROVEMENT
C OTHER
SQ. IT. FLOOR AREA $/SQ. FT.
VALUATION
OVVS' RIES PE CONSTRUC IO'.
r Z7/a
OCC. GROUP APN
OUILDING DIVISION FEES
PLANCHECK FEE LT
i
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
—�Date Race ip N
\0 TOTAL:
BUILDING FEE `
SF,ISMIC PEE
I
IC . O
NG FEFNICAL FE
UCTION AX
G SI TED TION FEE
Date greasing
TO
ISSUAN EDATE
ISSUED BY: