29520APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
FEE
PERMIT ISSUANCE
❑SPOWL
BUILDING - ELECTRICAL
❑ADDITION
PERMITNO. ^ [
BUILDING DIVISION
APPLICATION/PERMIT
PLUMBING -MECHANICAL
OVER Igl(IAMPS
L O J Z O
SIGNS ELECTRICAL
IMPROVEMENT'
SPECIAL CIRCUITMISC.-
BATH REM R REA
BUILDING PROJECT' IDENTIFICATION
OTHER
POWER DEVICES
BUI
DN DD SSS:/1
COMMERCIAL
OUTLETS- SWITCHES_ FIXTURES
❑NEWBLDGIADDITION
NEW RESIDENTIAL ELECIR S
SANITARY
NO.
APPLICATION SUBMITTAL DAI
- ALJI
PLUMBING PERMIT
OW P 'S AMC:
P Opliff
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CONT UTOR:S. AA LI 'O�
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CON IACT:
PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affi. But 1 am licensed umler pmvisions of Chapmr 9 (commencing
QOwith S.cd.n]Ut0lof Division Sof Elie Business Bud Profession, Code. and it, if«n¢is
in full farce and <HaK`�J
U U License s l.• f• Lac. #
Z W Contractor
pq CHITECTS DECLARATIO
y 7, 1 underseas] or, plans shall be used as public records
�W Licensed Professional
f� OWNER -BUILDER DECLARATION
C 1 hereby affirm that I am exempt from the Comracmr s License law for the
6 V following reason. (Section 7031 5. Business and Profeseiom Cvdm Any city or county
LLONa which mquims a permit to comtrnm, alar, improve, demolish, or repair any %racture
m.] prfono its issuance, also requires mcapplican, bersuch permino file a diamil'asucaem
}
On he is licensed pumuanua the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7")of Division 3 ofthe Business and Professions Code)or
e C Na he is exempt therefrom and the basis for the alleged exemption. Any violation of
rn Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
z } not antic than fisc hundred dollars ($50().
= G ❑ I, as owner of the properly, or my employees with wages as their sale compensation,
F will do the work. and the structure is not intended oroffeted far vale (See A0PLL Business
3 and Professions Code: The Commutar's 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 improvements arc not intended or offered for
sale. If, hnweveq the building or improvement is sold within one year of completion. the
owner -builder will have the burden of proving that he did not build or improve for par -
pose of ale.).
C 1, azeo
r of the ppe ny, am exclusively contracting with licensed contractors to
Insect theovica (See nHJ, Business and Professions Code:) The Contractor Li-
censelawdesnotapplytoanownerofpmpenywhobuildsorimprovesthemon,and QTY.
who camracts forsuch projects with a contradm(s) licensed am,mun to the Contractor's
License Law.
❑ I am exempt under Sec. ,B&PC for this reason
.Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirmunder penaltynatty of perjuryone oRhcmcame mg Wmkee Co
❑ILove and will for
maintain Certificate of beemasCode. burt for Wmkerseofthe
Corsica-
", far r provided for by gs issued, 3]10 of the Labor Cole, for the performance of the
work for entre this permit d, (,mm.
ILII I have and will maintain Workers Compensation Insurance, as malmood by Section
1 of the Labor Code, for the perfommocc of the work for which thu permit is issued.
My Workeya Qrmp ltvation Insurance currier and Pnlicv nwnM a . _ _ _
t r1Kl Pu_AltUPEXEMPDONFROM WORKERS
COMPENSATION INSURANCE
or Ice,.) « rte
(Thi, section d Be, he comploed if 'he pmt
eit is foams hundred W
dui lar,($1 )
1 certify 'hut in the purlilnnanee of the work far which this pemtit is issued, I shall
me employ any pawn in any manner sr, a, to become ,Object m the Worker,' Compen-
0 Z .cation Laws m Calffnmia. Date
Z Applicant
y NOTICE TO APPLICANT. IL after making this Craddra m of Exemption, you .should
a; hermov object to the Worker:, Compensation provisions of the Lass, Code, you most
ELI fmthwM comply with such provisions or this permit shall he deemed revoked.
% n
Uz CONSTRUCTION LENDING AGENCY
L. l hereby Offirm the mit i as a construction lending agency for the performance of
fYU the der'sNfor which this permit is issued l5cc. 3107. Civ. C.1
Q U Lender Name
(ander'AJdfcss
I certify that 1 have real this application and slate that the shove wation u
h carred. 1 agree to comply with all cup and mums nrdfnanas and stare laws s relrelating to QTY
U u buildingconstruction.
pm,any for
reby inspection authorize Of this city toemeropon the
above-memiond pmpenY for inspection purposes
(We) agree m save, indemnify and keep harmless no City of Cupenino got.,,
liabilities,judgments, costs and expenses which may in any wary accrue againn said City
in consequence of the granting of this permit,
APPLICANT UNDERS'TANUS AND WIIJ,L COMPLY WITH ALL NON -POINT
HAjf,RDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous material
as defned by dm Cupertino Mmasiled Code, Chapter 9.12, and the Health and Safety
Calc. Section 25532my?
❑Yes F1No
Will the applicant or future building accupem use equipment or devices which
Bit hazardous air contaminant, as defned by the Bay Area Air Quality Management
District?
❑Yes ❑No
I have read the haurdou, numdals requirements under Chapter 6.95 of the Cafi-
fomiB Realm & Safety Code. Sections 25505, M533 Bud 25534.1 Binational Nm if the
building docs not currently have o tenant, Nat it is my re,rymsibilry In notify the occupant
of the tequiremmots which must be met prior to issuance of a Certificate of Occoodwy
Owner or malmor and agent Dam
ELECTRIC PERMIT
FEE
PERMIT ISSUANCE
❑SPOWL
APPLIANCES - RESIDENTIAL
❑ADDITION
PANELS
UP TO 200 AMPS
[]MULTI -UNIT
201-1000AMPS
OVER Igl(IAMPS
1:1 INTERIOR
SIGNS ELECTRICAL
IMPROVEMENT'
SPECIAL CIRCUITMISC.-
BATH REM R REA
TEMP. METER OR POLE INST.
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
COMMERCIAL
OUTLETS- SWITCHES_ FIXTURES
❑NEWBLDGIADDITION
NEW RESIDENTIAL ELECIR S
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
- ALJI
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROGER AREA, COND.
FIXTURES - PER TRAP
GAS - G. SYSTEM -I INC. Y OUTLETS
GAS - EA. SYSTEM-OVER4(EA)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 IT.
WATER HEATER WIVENTELECTR
WATER SYSTEMOREATING
WATER SERVICE
NEW RESIDENT IAL PLMB. SQ. FT,
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IQ000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT(TO 100,00BTU)
HEATING UNI I (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP CHP OR 110,000 BTU)
BOILER -COMP(OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. PT.
OFFICE
❑ ❑ ❑ A
JOB DESCRIPTION
RESIDENTIAL
❑SPOWL
O KITCHEN REMODEL
❑ADDITION
O PLUMBING REPIPE
[]MULTI -UNIT
[]STRUCTURAL
MODIFICATION
1:1 INTERIOR
OCHIMNEY REPAIR
IMPROVEMENT'
BATH REM R REA
OL 0
OTHER
1
COMMERCIAL
❑NEWBLDGIADDITION
❑DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA
STORIES TYPECONSTRUI
IWAII 2 8 1996
OCC. GROUP AVN
BLDG. INSPEC ION DEP
An
1-1
BLhEbI9G WVP 3&PIEPTIMn
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE �..,
PAID
Do" Receipt
TOTAL:
BUILDING FEE
FEE
SEISMIC FEE
. O ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE # `'
CONSTRUCTION TAX O
HOUSING MITIGA{�N F
1
I' -J
�.
PAID 1.1 't •^ �—