S 1372APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOB,DING - KLEC`1 RIC,AL PERMIT NO. 1372
BUILD!N VISION APPLIC,CI'IONTERMIT I.1,UNIBING-NIE.c1IANICAI' l`:
_ RIIILDING PROUF.CT IDEN'I'II'ICA'1'[ON
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oMMIA
l kt—: ( l g&AN 1,194. I ❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provisions of Chapter 9lcommermng
Z with Section 7000) of Division J claim Business and Professions Code. and lay license is
mom° in mE farceand eaccl.
Q, U U License Chis' [.it. a
F+zM Oea Cmnta,an
VViid LL ARCHI IPC I'S DECLARATION
o=Z 1uadno
snd nay Plans vhall Ie. -it si
as ppheme x
OZ=Q
F'GIF LL: Licensed Porde"ionul
OWNER -BUILDER DECLARATION
C G 1 hereby affirm that I am exempt nom the Commmor's License Law for the
x4 i U thowmg reason. (So,, 1 7031S, Nuvineae and Pr..f ..tons Codo Any eiry or ,,only
aJ 3 WH whiel, ria.. a Permit ah cnnstract, alter, Improve, demolish, or repair any stuciam
F to aano it,i.ssuance,:axa raiuirea Imapplicn,lin' such pc nn it to file aei,ncd,mmrmnl
' that he is licensed purauunl to the provisions of Ne Contract %Lecnsc law (Chapicr0
� Icommencingss'ith Section 100nof Division 3 of the Bulinus and Professions Cdde) or
a 6 cC that he is exempt therefrom and the Iasis for the alleged exemption. Any violation of
ad Section 7031.5 by any applicant for. a probit subjects the applicam to a civil penalty of
W =Zancuwre than five hundred dollar, ($500).
❑ Las owner the propcnyo my employee with wages asthcir-le...cipciterta,
=o
[� Ill chore at sad': Ile,coma.aol,,iia,c Law does al apply ,, a.Bus
iia
W
3 $ load rmR.xim,. eane:'rllc Canlmmars Elapse Law saes roll apply m a owner of
property who builds or improves hereon, and who does such wink In sclfor through
hisemployees, provided that such inlIt terminal are nil intended or offered far
sale. IL however, the building or improvement is mid within one yem ofnnnpletion, the
carcer,builder rill have the burden of proving that he did not build or improve for pun
A7Ia,w of sale,.
I, us owner of the property. am exclusively connecting with Ilicensed contractors to
construct the project (Sec. 7044, Bmincsr sur Pmfevsi ms Cale:) The Cirri Li-
mLaw due ...... ply a an owncial pmficny who holdst nom ulhcrfon. seal 'I'V.
who contacts for such pmn
jes with n cnniraclaus) licensed par aunt It) the Contractor
Liu a, Law.
0 1 am exempt under Sec. . P & V C for this reaam
Data
cr OV EN:S )ME ;I�AllION sPLARATIO
I botchy amus under Pentlty of lrerjuryo of the fnlhswing Aulurulinns.
I M11n aJwilla norm, uCcniticumul C atowll-inmmhat Worker's Conopen-
,all
pen
sof ion, as aa,i,sJ Int by See fmn 371X: of the I.ahor Code, or ha penlomnana uI the
work fm which rots larmit is issued.
Fl 1 have and will maintain Worker's Compensation Insurance, as claims] by Semina
37M of the LaMn Cole, for the performance of the work for which this feral is issued.
My W'orker's Compensation Insurance carrier and Policy number am:
Cmricc Policy No.:
CERTI incNTE OF EXEMPT ON I"ROM WOR KIi RS'
COMPENS A IION I NS U RANCE
I Laj%scetion need not ha campleed it the pcmtit is for one hundred dollops IS I (to)
sir less.)
I ccnify that in the perfmmxncc of the work for which this permit is issued, l shall
not employ any pat in any manner sons,, become subject to the Workers' ComNn-
Q Z olmn laws of Car occur. Date
Z
O Applicant
NOTICE 10 APPLICANT If, after making his Certificate of Eser,amn an should
socialite .h,,,I Im the Workllx C.mpcnsation pat, ,n of he Labor Cae, you ate
w ranhwim cm„ply with etch era ns ,t his pe vision,
sholl he demacd evoked,
Q
Z) CONST RUCTION LENDING AGENCY
U O I hereby affirm that hem is a construction lending agency for the performance of
W. 1"' the work far which his permit is issued ISce. 30,G. Cil C)
Q U Lcndee, Name
U.l Lender's Address
EL I ccnify,hnl I have read this upplicntion and state Ihm the above inliamatinn is
V. s red. I ugac la.simply with.11 cloy and county oabarra,e, and site laws rel—nova Q'rY.
U Z bmido,en motion. pool hemby mumori-mere cnmtivaeol a, city bit roper Too the
nip vcmanioned propeny far inspection popoxes.
(We) agmc a sore, indemnify and keep harmless the Civ of Cupertino against
hishilities,judgments, coats and expenses which may in any way aecme.,.last said City
in nseciance of the granting of this permit.
APPLICANT UNDERSTANDS AND W'ILI, COMPLY W'1'11I ALL NON -POINT
SOURCE REGUI.At IONS.
/ r t�7 .
HAZARDOUS MAI IiRI 1 S DISCLOSURE
Will the applicam or owre building a vpanl score or M1anJle hmaNuus material
re defined by the Cupertino Municipal Code, Chapter 9.12, and the llcahh and Safety
Csda Section 25511(u)7
[3 Yes El No
Win the uppllcun. or future builAing x vpvm use cyui,awnt orJamecx which
1 M1aearl-, air commmennts as dutinvJ by the Bay Area Air Quality Management
tictt
❑Yes One
1 have mad the hweNous materials requirements under Chapter 6.95 of me Culi-
hmia Health & Safety Cure. Sections 25505. 25533 and 25534. 1 understand that if the
holding Joos not ntrmnlly have n tenant, hut', is my respartabi lily to motif y the mvvpen
of the ox,muenentx which must be net fill...,, insmmcc of u Ccnilicata 01 Ouupaney.
I°LECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCILS - RESIDENTIAL
PAN&.S
UP TO 200 AMPS
SIGNS ELF.CI'RICAI, z
still
SPECIAL CRCUI UMISC.
'TEMP. IIEIIiR OR PULL INST.
POWER DEVICE -S
SWIMMING POOL ELECTRIC
OOTLEI:S -SWI ICHHS - FIXTUR12S
NEW REMDIiN'I'[A]. ELECTR
SQ lT.
L
PLUM BIND PERM I'I'
PERMIT ISSUANCE
ALTER- DRAIN k VENT -NATER U:A)
BACK FLOW PROTECT. DEVICE
DRAINS - VLOOR. ROOP. AREA, COND,
FIXTURES - PER 'I'RAP
GAS - P.A. SYSTEM -I INCA DOE LETS
GAS - EA. SYSTEM OVEE /IN
t r
(1REASI]INI'R"IIS'I'RL A , :INI'1:
IREASIi'AP I)
SEWER - SANITARY - S WEA
WAl F.N lT l I:M/ 1 ttL/tl IIS
WATER SHEVICIi
NEW RESIDENT IAL PLMB. SQ. ET,
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.1NXE CFME
Alit HANDLING UNIT (OVER I t),kXE CEM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT TO 100.000 BTU)
HEATING UNIT (OVER 100.000 BTU)
VENT LATION PAN (SINGLE BESIDE
BOILER - COMP (311P OR I OPEN) If I'In
BOILER - COME' (OVER ]MORE 111 BE
AIR CONDITIONER
NEW RESIDEN I'I AL MECH. SQ. ET
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BLIP I' . 0its Ml:l:ll
i/j��1\_izrf�\
FEE JOB DESCRIPTION
RF,'1 1
'F>Wh ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE:
❑MUU11-UNIT ❑S I'RUC 'FURAL
MODIFICATION
❑lWERl IR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOIS
❑ BATH REMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
all '01
FR I '
[I NEW BLDG/ADDITION [I DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
Polf3SQ. Flt FLOOR AREA S/SQ. I,
it-it��
FEE cc-a�C�,
3ts3tfag
STORIES 11'I'YPECONSTROC'I'ION
FHE!%
SOILS FITE
Af
PAID
Reectio #
Q1'AL:
BUILT 'I.i
FEE SEISMIC iE
ELECT ''HE
PLUMBIN' ITH
MECHANICAL FEE 1
CONS 'TRUCI'[ON 'TAX
IIDUSING MITIGATION FEE
PAID_ �SLL
Date ReeciplN
ISSUANCE LINE F
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