28798APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION
au3
APPLICATIONIPERMIT
BUILDING
UWN S NAME: FHONL. I I CONTR IOR'S NAhIE-� IJ
3 S /A ❑Consultant Pecs Paid by Applicant (Initial)
1 hereby affirm that 1 um licensed under provixinns of Chapter 9 (mina firing '
Z with Section 93300) of D�EARCHITFCTS
aBusiness writ Pr it reaons Cole.ar�mylicenxi,.
�cco fuurotceandenter.3 Q! ..
U License la Lic.p
DECLARATION
Z O - Z 1 miller. mal my plans shall be fixed as public records
OZ=_
G' F = Licensed Probe ss.nnul
y,y OWNER -BUILDER DECLARATION
y C w Q I hereby tdlirm that 1 am exempt from the Connaao,', License Law for the
x 3 LLU following mason. (Section )1131.5, Business and Professions C,de: Any city ar county
y which requires a permit to constrvct, filter, improve, demolish, or repair any structure
priano its issuance, do) rc9fiircx the applicant nor such penniuo File u signed statement
f that he is licensed pursuant to the provisions of the Comrktor's License Law (Chapter 9
Wp'QD (commencing with Section 7000) of Division 3 of the Businessand Prtfta,iZ oCode)or
2 %e LLthat he is exempt therefrom and the basis for the alleged exemption. Any violation of
N Section ]031.5 by any applicant for a permit subjects the applicant to a civil pewlty of
not more Nan five hundred dollar. (5500)
Sp
LJ 1. as owner arrive properly, or my employees with wages n, their.sole compensation.
F- will dote work. and the structure is not intended oroffned for sale (See, 704,1, Business
a3 m and Professions Cede: The Contractor's License taw does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
In, awn i mployen,, provided that such ioProvententS are not intended or offered for
sale. IL however, 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 pur-
pose of sale.).
❑ h m owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 704cl. Business unit Professions Calc:) The Contractor's Li-
u Use does not apply to an owner of property who builds or improves thereon and QTY,
who commas for such projects with o contractor(s) licensed pursmnt to the Contractors
License Law.
❑ I am exempt under See. ,B&P C for this moxa
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby offirnl under penally of pc Jurymm of the following Jed,oldom:
❑ I have and will maintain a Cenilicam of Consent teselbinsure for Workers Compirm
sarion, as provided for by Section 3700 of the Labor Cede, for the perfa imine of the
wm 4>t hicM1 th, permil i. issued.
I have and will maintain Workers Compensation Insurance, as requited by Section
3700 of the Luhor Code, for rhe pcnbrmm®e lathe work for which this pa nu n iuweA,
My Worker's ump�ensa}y Inx., cecaxier and Policy n bj.l
Cartier._((! Q _L'�_ Policy No.:
ERTIFICA'1'E OP IiXEM I'I']ON PROM WORKERS'
COMPENSATION INSURANCE
Tlhis section need nil he completed if the pnnnil is tin one hundred dollars 01Pill
or less)
1 eatify that in the performance of the work for which this Permit is issued, l shall
noI cmpby any pm,on in any manner so as m became. amort,, tire Workers Cnmpen-
Iz satiun lawsof Califomia. Dae
.Z.t O Applicant
M NOTICE TO APPLICANT: If, attar making this Certificate of Exemption, you should
a , become su comply
the WmrkaS Compensation onail that
b the Labor Cede, you must
LEI ftnM1whM1 cantply with such pravininnx or this permil shell M: Jccmcd revoked.
Q
IY CONS'I'RUCTION L[NDhYG AGENCY
U 0 I hereby umrm that there is a aonswclimn lending agency for the performance of
V. F' the work for which this pandit is issued (Sec. 309). Ci, C.)
O U lender', Name
Lender's Address
Hper, 1 certify that 1 have read Isis application end slate that the above information is
W correct. 1 agree to comply with all city and county ordinances and slate laws relating to QTY.
U Z buildingeoustructlon. and hereby amhoriu rtpresenmtivesoOdd, city menterupon tote
above mmmtin led prorymy fir impeclion pmpow,.
(We) agree to vve, indemnify and keep harmless the City of Cupertino agalnn
liablldies,judgments, costs and expenses which may in any way acerve ageinsl sail Ciry
nucquencc of the granting of Ihls )mrntit.
APPLICANT UNDERSTANDS AND WILL COMPLY IVITH ALL NON -POINT
SOURCE, REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant store or handle hazardous mmedal
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cade. Section 25532m)R
E] Yes r-1 No
Will the applicant or enure building occupant use equipment or devices which
mit hurard u, air contaminants as drained by the Bay Area Air Quality Management
Disinter?
❑Yes' E] No
I have it the hmzubm, maedal, requirements under Chapter fi 95 of the Cali-
fnmia Head, & Safely Code, Sections 25511.5, 15533 and 25534. 1 undenWnJ that if the
buildm obex not currently have o tenant, that it is my responsibility ran `YLhZcupam
of lh tiioTans,yllnch must lic mel Immto issumtce cora Certircai/of ocel(Ityncv.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
OT TO PIX) AMPS
201-IMAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TAMP. METER OR POLE INS'I'.
POWER DEVICES
SW MMING POOL ELECTRIC
OUTLETS - SWI I CHES - FIXTURES
NEW RESIDENTIAL ELI2M'R
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT -WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, GOND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLEIT
GAS - EA. SYSTEM OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASE'1'RAP
SEWER - SANITARY- S'IORM 15A. 2001`1`.
WATER HEATER WNE,NTMLECTR
WATER SYSTEMO REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. red.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IO.R* CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD OVIDUCT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER IU(L000 BTU)
VENTILATION FAN (SINGLE RESID)
MOILER -COMP (3HP OR 100.000 BTU)
BOILER -COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MUCH. SQ. ET.
OFFICE
61
FEE
FEE
JOB DESCRIPTION
FLKMLI NU. 2 8 7 9 8
NITARY NO.
APPLICATION SUBMITTAL DAL
❑ KITCHEN REMODEL
❑ADDITION
?-2/- P/_
N/C
❑STRUCTURAL
CONTROL It
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
BUILDING PERMIT' INFO
BI,DG
ELECT PLUMB MI3C
❑
❑ ❑
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RF -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL/REPAIR
❑DEMOLITION
❑ OTHER
COMMERCIAL,
[I NEW BLDG/ADDITION
13 DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
I ti SQ. FT. FLOOR AREA $/SQ. FT
SEP 2 A
BUILDING DIVISION FEES
PLANCHECK FEE
ENRRGYFEE '
GRADING PEE
SOBS FEH
PAID
Dae RscriptB 1
BUILDING FEE
FEE ' SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
V MECHANICAL FI7E
CONSTRUCTION TAX
HOUSING MITIGATION FEE
IPA"'
ume Recdpta
TOTAL: _ a ,, _
ISSUANCE DATE