S 0589APPLICANT TO FILL IN INFORMATION WITHIN
APPLICATION/PERMIT
u,Csp
CONTACT:
BALL POINT PEN ONLY
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CON' TRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT EEE
I hereby aRrm that I am licensed under provisions of Chapter 9 (commencing
with Section 7")of Division of the Business and Pmtessions Code, and my limensc is PERM IT ISSUANCE
infullforeea,dc col. �{
Licens loss I -it # APPLIANCES -RESIDENTIAL
Date Contra A �—� �'�
ARCHITECTS DECLARATION PANELS
1 understand my plans shall be used as Public records
UP TO N00AMPS
—4t
4C Y� Licensed professionalCYC,OWNER-BUILDER DECLARATION
yy OG i I hereby uRrm that I am exempt tram the Contractor's License Law for the
Uy. following minor. (Section ]031.5, Business and Professions Code: Any city or county
Y 3 0 N which requires a permit to consumer, alma impnwe, demolish, or repair any sanncmre
��� priormimissuance, ulsorequires the applicant formch permit none a signed smeement
} that he is liansof uncesmman, provisions of Ne Communes License Law, (Chapter 9
W a�O (commencing with Section 700b of Division 3ufthe Business and Professions Code)or
d y o y that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
W y Section 7031.5 by any applicant fora pemsit subjects the applicanno a civil peml y of
t mare than live hundred dollars ($5IX).
❑ 1, u owner of the properly, or my employees with wages as their sole compensation.
will do the work, and the structure is not intended or offered for sale (Sec. ]DW, Business
6 3 and Professions Cade: The Corrosions License Law does nut apply m an owner of
property who builds or improves thereon, and who does such work himself or through
hisn employees, provided that such iniprovemenu, am no intended or offered for
m1e.IL howtvm, the building or improvement is sold within one year ofcompictim, the
ter -builder will have the burden of proving that he did not (wild or improve for pur-
pose of cola).
D 1, as owrer of the property, am exclusively contracting with licensed contractors in
construct the Project (Sec. 9044, Business and Professions Csd JTheContractorsLi-
cense Law does not apply to an owner of property who builds or improves thereon, and QTY.
who commas fbrsuch projects with a counteracts) licensed pursuant In the Contractors
License U.
I am exempt under Sec. , B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
�I have and will maintain a Cenumare of Consent o self-insum for Workers Cameo -
non, as provided for by Section 37W of the Labor Cole, for the performance of the
work for which this pools is issued.
NI have and will maintain Woherc Compensation hommaim. as required by Section
3 (1(l of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy
Cameo Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('This sermon indoor becnmpleted tithe permit is forme, hundred dollars PH W )
orless)
1 certify that in the performance of the work for which this permit is issued. l shall
nor employ any person in any rammer so as to become subject in the WorkersCompen-
,� sation Lows of California. Date
Z Applicant
NOTICE TO APPLICANT. If, after making this Cenificare of Exemption, year should
become subject o the Workers Compensation provisions of the Labor Code, you must
Wforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCV
Vti I for which this
thereissued(Set. 3097ion lending agency soba perfannantt of
(Y Ne wodfnr which this permit is issued (Sec. J09], Civ. CJ ,
O ULenders Name
W Lenders Address
yI I terrify that 1 have read this application and slate that the above information is
y crime, l agree to comply withal] city and county ordinances and state laws relating m QTY
L) Z building construction. and hereby amhorize repmaamtivw of this city rte enter opera the
above-mcnrimmil property for inspection purposes.
(We) agree to save, indemnify and keep modem the City of Coproma against
liabilities, judgments, costs and expenses which may in any way accrue ugalnst sat
inamsequNT umthFlUITA DSthis permit. «l
APPraCANT uNDF31rPANDS AND WILL COM Y D I I POI T
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazamous material
as defined by the Cupertino Municipal Cede, Chapter 9.12, and the Health and Safety
Code, Section 25532od?
E) Yes -1 No
Will the applicant or future building occupant use equipment or devices which
rah hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes 0 N
1 have read the boarders mamsids rtquiremems under, Chapter fi 95 of the Cali-
fbmia Health & Safety Cole, Sections 255115. 25533 end 25534. I understand that if the
building does nm rymardly haven moral that it is my responsibty to not fy the occupant
OVER 1080 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE. INST.
POWER DEVICES
OUT LETS -SWITCHE
NEW RESIDENTIAL ELECTR
PLUMBING PERMIT
SQ P -L
PERMIT ISSUANCE ACL
ALTER - DRAIN & VENT- WATER HA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GRFASFIINDUSTRL WAS'I INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 200 Fr.
WATER HEATER WIVENI'/ELECTR
WATER SYSTEM/rR1ATING
WATER SERVICE
NEW RESIDENTIAL TIME. SQ. Fr.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CPM)
EXHAUST HOOD(W/DUCI)
HEATING UNIT (TO 101.000 BTU)
HEATING UNIT (OVER 100,(10(1 BTU)
VENTILATION FAN (SINGLE RESUB
BOILER -COMP (311P OR 100000 BTU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, FT.
F JOB DESCRIPTION
S 0589
NITARY NO.
DADDITION
APPLICATION SUBMITTAL,
D MULTI -UNIT
❑ STRUM URAL
Ma
ODIFICATION
NIC
CONTROL#
El
SWIMMING POOLS
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
❑ ❑ ❑
F JOB DESCRIPTION
RESIDENTIAL:
O SFDWI,
D KITCHEN REMODEL.
DADDITION
OPLUMBINGRE-PIPE.
D MULTI -UNIT
❑ STRUM URAL
ODIFICATION
❑INTERIO
MIR
IE
SWIMMING POOLS
D BATH RGMODEI/RF.PAIR ODEMOLFRON
❑OTHER
COMMERCIALa
❑NEWBLDG/ADDITION DDEMOLGHON
OTENANT ❑ FOOD SERVICE
IMPROVEMENT
DOTTER
SO. FT.. MOOR AREA ESQ. 14.
PAID
%a 19 RECD
CITY ur s, L(R'TIKU
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY LBF.
GRADING FEE
SOILS FEE
PAID
Date Reeri"#
BUILDING FEL!
FEE SEISMIC PEE
_ ELECTRIC FEE
PLUMBING FEE
MECHANICAL. FEE
CONSTRUCTION' TAX
HOUSING MITIGATION FEE
PAID
Dam Reit ,a
DATE