29593APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATIONMERMIT
BUILDING
❑ Consultant Fees Paid by Applicant (Initial)
1 hemby affirm ,hat I am licensed under provisions of Clopmr 9 (cola fancin,
WOO with Section 7") of Division 3 of the Business and Rofessinns Code, andmy licensees
aUO in full force ande /T
QUU License Lic.# (92-
W 'lot Date Cnntm'lot ✓
. RCHITECT'$ DECLARATION
Z p N 7, I understand my plan., ,hall be uwd a, public records
OZ -0
Licensed Professional
OWNER -BUILDER DECLARATION
O
C W Q 1 he by uffrm that I of exempt Gust the Cu ntraator's License Law for the
iq5 a U following reason. (Section 7031.5, Business and Professions Code: Any city or county
w+ 3 w y which requires a Kraft to construct, alter improve, demolish, or repair any structure
Ro, priorto its issuance. alio requires the upplicantfor such Permit to file a signed statement
Y y'' that he is licensed pursuant n the provisions ufthe Contractor's License Law lChaptari)
W-00 (nommencingvsith Section 7")of Division 3ofthe Business and PrdessionsCde)or
6 q 0 C that he is exempt 0,eafmm and ,he basis for the alleged exemption. Any violation of
YXI ay
Section 7031.5 by any applicant far a permilobjecr, the applicanuo a Old penally of
F Z } not more than five hundred dollms 1S50E
D I. as uwrterofthe property, ormY employees with wages ax their late compensation,
g.. will dothcwork, and themardere is not intended orofl'erd first (Sec.]OM, Bnsine.ss
a3 m and Professions Code The Contractors License Law doors not apply at an owner of
Property who builds or improves thereon, and who Jots such work himself,,, through
his own employees, provided that such improvements arc not intended or offered for
sale. IL however, the building of impmvantont is sold within one year of completion the
wneobuilder will have the burden of proving that he did not build or improve for pur-
,ov of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
conutr sO the project (Sec. TA,L Business and Professions Cde:) The Contractors Li.
cause Law docs not apply to an owner of proPery who builds or improves thereon, and QTY
who contracts for such projects with a connections) licensed punmot to the Contioni
License Law,
❑ I an exempt under See B & P C for this reason
Owner Date
•
WORKER'S DECLARATION
ffi
1 hereby arm undernderpenalty of Ic jury one of the following Wmkm`,,C
D I have and will for by n aSc Ciar13700cate of Com ob,oter Ce le.fore for Nbrkers Cc of the
#tion, r provided hich,hi for de Snmion 3?!10,,Tobe Labor CttM;, for the perl'ormanee of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
X) of the Labor Code, lin the performance of the work for which thin permit is iscu d.
My Work pc tion Inxopcea,mcr and Policy n
r o14 -ACarrier.Policy No.:
CERTE "AD EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
of les'.) his seer
(T.. need not be completed ifthe Kmfn
art is rone hundred dollars (SI (in)
I certify that in the performance of the work for which this Permit is i.aved. I shall
not employ any Person in any .tanner so as to become subject to the Workers' Compea-
Z lotion laws of Colateral.. Date
Z O Applicant
sr cnNOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
a5: become subject to the M'arker's ContPensation provl lions of the Labor Cad,you into
W forthwith comply with such provisions or this Permit shall be deemed revoked.
a�
.U. z CONSTRUCTION LENDING AGENCY
U O I hembyich thi tomthere is issued
lending egencY for the Performanec of
0 F the work for which this permit i, issued (Sec. 3097, Civ, C.)
U Lenders Nana+
W Lenders Address
As 1 hardly that 1 have read this application and nate that the #More inr...... n is
V) correct. 1 ugtce to comply with all city and county ordinances and state laws relating to QTY
L)z building concwdi,,n. and hereby authnrife representatives of this city 10 enter upon the
above.mentiund propery for inspection purposes.
(We) agree n, save, indemnify and keep hartnlec the Goy of Cupertino against
liubilitiex,judgments, costs and expenses which may in anyway acrue again# said City
nxequence of Nc,renin, c fnis pconal,
APPI:IICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
HRODUS MAI ERIALS DISCLOSURE
Will the applicu or future building two,com noreor handle haemdoux malarial
as defined by the Cupertino Municipal Cde, Chapter 9.12, and the Health and Safety
Cde. Section 255321x)!
-1 Yes C] No
Will no applicant or future building (occupant use equipment or devices which
mit hazardous air commensals as delind by the Bay Area Air Quality Management
'Ikcrict?
❑Yes ElNo
I have red the h rmadue, materials requmentemx under Chapter 6.95 of the Cali-
humia Health & Safety Cde, Sections 25505, 25533 and 25531, I criterion, that if d ,
builling docs no rally have .enol. ,u amy,f gtonsihditymnotify the (tecuupant
of, �eryyremare w h.nIcabe met �nLL Ahf.r...irnfl..r
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITMISC,
TEMP METER OR POLL INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTS SQ FT
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER- DRAIN & VENT _ WATER lEA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM OVER Y (EA)
GREASEANDUSTRL WASTE INTERCEPTER
GREASETRAP
SEWER -SANITARY- STORM EA. 200 FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEMTREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. FE
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT LTD 10.000 CFM)
AIR HANDLING UNIT (OVER 10,1100 CPM)
EXHAUST HOOD GIODUCT)
HEATING UNIT (TO 100,000 WILL
HEATING UNIT (OVER IBB.BUo BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER -COMP OFF OR 100,0011 ETU)
BOILER -COMP (OVER 100,000B'ru)
AIR CONDITIONER
NEWRESIDENTIAL MECH. SQ, IT.
OFFICE
❑SFDWI.
D KITCHEN REMODEL
29593
D PLUMBING RE -PIPE.
D MULTbUNIT
SANITARY NO.
APPLICATION SUBMITTAL DAT
MODIFICATION
D INTERIOR
DCHIMNEY REPAIR
-zq QG
D BATH REMODEfJREP
R DDEMOLITION
DOTHER
rvfC
COMMERCIAL
DNEW BLDG/ADDITION
CONTROL#
OTENANT
DFOOD SERVICE
^IMPROVEMENT
BUILDING PERMIT INFO
BLDGEL
.UYfB MECH
FEE
❑SFDWI.
D KITCHEN REMODEL
DADDRION
D PLUMBING RE -PIPE.
D MULTbUNIT
C1 STRUCTURAL
MODIFICATION
D INTERIOR
DCHIMNEY REPAIR
IMPROVEMENT
D BATH REMODEfJREP
R DDEMOLITION
DOTHER
COMMERCIAL
DNEW BLDG/ADDITION
ED DEMOLITION
OTENANT
DFOOD SERVICE
^IMPROVEMENT
JSQ. IT: FLOOR AREA.
AUL 2 91996
FEE
rlrr L' LV("'LfilI16U
FEES
PLANCHECKFEE
ENERGY PEE
GRADING FEE
SOILS EEE
PAID
Dam Receipt N
TOTAL:
BUILDING IEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING IEE I
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Data Receipt#
TOTAL:
DATE
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