S 0151APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL
CITY OF CUPERTIN
BUILDING DIVISION
PEN ONLY
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED 6pNTRACPOR'S DECLARATION QTY ELECTRIC PERMIT
1 hereby affirm that I am licensed under provisinns of Chapter 9 (commencing
with 5ation l000)af DivixirnJofthe Business end Professions Crde,md my license is PERMIT ISSUANCE
in full force and effect.
License Class Lica APPLIANCES-RESIDETPIAL
Date Contractor
ARCHITECTS DECLARATION PANELS
1-6dentio plum Mlown.spublicrfc ad, 'O4P DP TO 200 AMPS 4
fidYUWNeK-amLULR ubu.AIsAUory
C of 1 hereby affirm that I am exempt from the Contractor's License Law for the
gi 3 LL F fallowing reason. (Section 7031.5, Business and Professions CMe: Any city or county
which mquims a permit to eooswer alters improve, demolish, art repair any ..arm
FSO pd., to its issuance, also require, he applicant froundap.am file..gaudsunemem
i y that he is licensed pursuanto the provisions of the Contractors License Law (Chapter 9
SWG�O (commencing with Section ?OIXBof DlvisionJ of the Business and Professions Gdc)or
GLy n y that he is exempt therefrom uad the basis for the alleged exemption. Any vialmion of
7e h Section 0031.5 by any applicant for a pouch subjects the applicant to a civil penalty of
YF not mum than five hundred dollars (SSW).
❑ I, as owner of the property, or my employees with wages as their sole compcnmtion.
will do the work, and the ,wn
ae, is not intended or offered for sale(Sec. 1044. Besides,
L 3 and Professions Code: The Contractors License law does not apply to an saner of
property who builds or improves thereon, and who does such work himself or though
his own employees, provided that such impovcaucros are not intended or offered for
sale. IL however, the building or improvement is sold within one year ofcompletion, the
owneT-builder will have the burden of proving that he did not build or improve for par.
Pare.1'saleJ.
❑ 1, as owner of the propcny, am exclusively coloracting with licensed contractors to
construct the project Sec. 70414, Business and Professions Code:) The Commctors Li-
cense law docs of apply to an owner of pmpeny who builds or improves thereon. and QTY,
who contracts for such projects with a contmcton s) liccmed pursuant to the Comractors
Licit... Law.
I am exempt under Sec. . B A, P C for this mason
wner Date
WORKER'S COMPENSATION DECLARATION
I berehy affirm under penahy of perjuryone of the following dEretion, as provided for by Section 3]00 of the labor Code, for the pework for which this Permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as req3700 ofthe Labor Cada forthe performance ofthe work for which this
My War CP pe cation fns}uanee cy* and Policy num
Currierk ¢Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm lse completed if the permit i, forone hundred Jallam (51 W)
or less.)
I cenify that in the perfmmarse afthe work fm which this permit is iasoed.I shall
nm employ any person in any manner so as to become subject to the Workeri Cmnpen-
Z nation laws of California. Date
7 O Applicant
a ffy//�3 NOTICE TO APPLICANT. If. after making this Cenilicate of Exemption, you should
f� become subject to the Workers Compensation provisions of the Labor Cele, you round
forthwith comply with such provisions or permit shall be deemed revoked.
0
CONSTRUCTION LENDING AGENCY
U 0(hereby affirm that there iso constmction lending agency for the perfommnce of
W. f" t the work for which this permit is issued (Sec. 3(1 Civ. CJ
O U Landers Name
{21 Leader',AW.s
1 certify that 1 have read this application and stem that the above information is
W correct. l agree to comply with all city and county ordinances and state lows relining to QTY.
U Z, building construction, and hereby outhorim opresenmtives of this city to enter upon the
move mentioned property for inspection purposes.
(We) agree to save, indemnify end keep famous the City of Cupertino against
liabilities,judgments, cods and expenus which may in my way accrue against said City
in coruquence of the formula, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hnvanlaus muedal
as defined by Ne Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety
Code, Section 25532md?
❑Yes FI No
Will the applicant or future building occupant use equipment or devices which
hazardios air curformams as defined by the Boy Area Air Quality Management
wt?
E] Yes r-1 No
L have used the bewdaus materials requirements under Chapter 6.93 of the Cali-
fmmie Health At Safety Cede, Satiorts 25505, 25533 and 25534. I understand that if du:
Wilding does not currently have m teem, thin it is my responsibility to nmify the accupmt
of the requirements which must he met pdor to issuance of a Certificate of Oacupmcy.
SIGNS EEE
SPECIAL CIRCUff/A.
'1' EMP. METER OR P :INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
)OUTLETS -SWITCHES-FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER- DRAIN A, VENT- WATER (FA)
GREASIANDUSTRI. WARIIE INTERCEPTOR
GREASETRAP
SEWER - SANITARY- STORM P.A. 200 FT.
WKUp- R t1EACE R WNENTRiI.ECT R
WATER SYSI'EM(fREAI'[NO
WATER SERVICE
NEW RESIDENTIAL PLMB, SQ, FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER RAW CFM)
EXHAUST HOOD UNMUCT)
HBATING UNIT (TO 1Og000 ETU)
HEAPING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RMIDI
BOILER -COMP 011P OR 100.001) BTU)
BOHJUI -COMP (OVER 110,1010 B'rU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. PT.
I PEE
FEE
C
BUILDING
JOB DESCRIP'T'ION
C-�-7 97
I.
❑ KITCHEN REMODEL
ADDITION
❑PLUMBING RE -PIPIT
❑ ULTI-UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑DEMOLITION
[I OTHER _
COMMERCIAL<
El NEW BLDG/ADDITION ❑DEMOLITION
E:1 TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ, FT FLOOR
`V
5/SQ. FT.
GG -7e33
BUILDINGDIVISIO PEES
PLANCHECK FEE
ENERGY FEE
GR N '%
SOILS FEE
poll
Dam Pt p
as
To &:
BUIL IN PI
FEE SEISMIC
ELEC SEISMIC F.i s ^
IC LLE
^ �
C� PLO, BING PEE
MEC NICAL FEE 70
CONS'RUCTION'1'AX
HOUSIllioMITIGATION FEE
PAID
Bae cciPt a_
ISSUANCE. DATE
C-�-7 97
ISSUED BY: JLzA
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RIM t0l-
Input Permit
'
Number :
PERMIT#:
RCHITECT:
/ALUATION: 44000
APN:
31628043
ICENSE#:
ISSIDATE: 06 17 97
'US STREET:
COLBY
3UBDATE: 06 18 97 LCHKDONE:
SITUS NO#:
10183
TYPE:
RSA
-ATE CODE:
,/E,CT,ST,RD:
AV
3LDGDEPT:
N,S,E,W:
ESCRIPTION: ADDITION
-NGDEPT:
NO#:
PLANDEPT:
CITY
CU
�LCHKREQ
CMA:
ZIP:
95014
:ATEGORY:
0
CTRFIRE:
-OT#:
0
)ATEDUE:
O6 18 97
SANDIST-
ID:-ILTHDEPT:
immerciml
OWNER:
OWNER
MARTIN LLOYD H ANC
10183COLBYAV
CA -so
CE-so;#Z;
3TRCTENG: TOTAL:
INSPHOLD:
ADDRES
CN-sci#fl#:
Y,STREET,ZIP:
)HONE:
CUPERTINO CA
4082539474'—
-sidential
RN-sq#ft#
27
)NTRACTOR:
DREWSHOOK
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[E:: 17412
Search by
UC#:
1637613
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