S 0477APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING
PHONE:
�C t s l ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATIONQTy GLECI'RIC PF.RMI'I'
I hereby affirm that 1 am licennesl under Is War, of Chapter 9 (commencing
with Section 7")al ToMsio' 3 of the Businessa'd Profession, Cale. andnry lieenxe is
[THEME 'I'ISSUANCE
In full force and effect,
License Class Lic.M APPLIANCES — RESIDENTIAL.
enact ARCHITECT'S DECLARATION
z���[r�aar I understand my dain.shall he used as Iodinemcards
Z�Q
IQ LL] Licensed Prnfic,o nal
•.1 OWNER -BUILDER DECLARATION
, 6 I hereby s0imt that 1 am enanpt from the Commctoos Limn c law for the
O y U fallowing reason. (Section 703 1.5, Business and Professionsmll Cale: Any can or county
3 W y¢ which reyulas o permit .e consruct, ober. improvg demolish, or Ills
any smenure
X03 )rondo its Oname, echo myuirea the nPPlicum for such pennil to IIIc uxigned smmnmm
that he is licenced pursnan0n me provi,sionsofthe Contrednrs License Law (Chapmra
W IYO� (commencing with Se i000)of Division 3ofNe business and Prof�ssiona Mr,") 'or
6 X n y that he is exempt therefrom and the basis for the alleged exemption Any violation of
4, Section 7031.5 by any applicant for a pencil subjects the applicant to a civil penalty of
�r notation, than five hundred dollars S.500).
.F+Z6 i, as owner of the norm m In ees with wu•es as thcin..le cam lion,
O Proptr y Ye P Y g penis
will do work. Coals. structure a tot s Limminr offeLaw
ed dos not apply to an Owner
of
W
3 m and property
who
Cale: The Contractor's Licsrsce Inw saes not apply s if owner gh
property who builds or improves thereon, and who doss such work himself ar Through
his own employee, provided that ouch immns sold tx nn not imend.d or offend lite
win,ILhowever. the
vethe boron of provint issoldwithinonbild ofmroveforpt-
wnenbuilderwill have the burden of proving that he did oat build or improve for pur-
P wo, of ale.).
1, as owner of the property, am exclusively contracting with licensed contractors in
,.,True, the pajem (Sec. 7044, Boniness and Prolessionn Calc:)'[he Contractor', Li -
c n • Law does not apply to on owner of property who builds nr Intpnrvew there'll). to QTY
who contracts for such projects with a contracmd,d limned pursuant to the Cmumeou
License law.
I am exempt under Sec, . B & P C for this reason
�OwneP Dole
o WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penahy de perjury one , the following Wo lave, Ca
(have onowill for 6,
of Cammnto atiff-Code. sureRPerfor ante Of
Camara -
adjust, as providedhhi tier mi Section 9]1X) of the Labor GIM,, for the Performance ar IM
work for which this permit is issued.
hail mn1 will mai main Worker's Compensation Irkf.r ce, h required by SmEnn
MyNl of the labor Cale, for the Insurance
carder
of the work for which Thin Pettit is incised.
Ca Waders Cnmpcnzmion Insurance carrierand Policy number arc:
Cnricc Policy Nn:
CERTIFICATE OF EXEMPTION FROM WORKCRS'
COMPundele'IONINSURA NCE.
('(Tis semina noel not he conlplemd if thepcmth Is for one hundred dollars ($ IINp
W tern.)
lcenifythat inthe performnce afire work for which this permit isissued, l shall
not employ any person in any manner so as to become subject to the Workels'Compcm
Z Blinn Laws of Culifomiu. Dote
Z Aldicum
NOTICE. TO APPLICANT: If, after making Nis Canilicate of Execution', You should
become subject to the Workers Compensation provisions of the Labor Cale, you must
forthwith comply with such provisions or this permit shall be deemed awaked.
Paz CONSTRUCI'IONLENDINOAGENCY
U I hereby affirm that there is a eonsnuction lending agency for the performance at
W H the work for which this permit is issued (Sec. 3097. Civ. C.)
O ULenders Name
U Lenders Address
G I aniry that I dive will this application and state that the above information In
0 correct. I agree b comply wit all city and county ordinances and smm laws minting at
U z building masonic, and hereby mahorire representatives ofthis city to enter upon 'he
abuse mentioned prapcny for inspeninn purposes
(We) agree m save, indemnify and keep harmless the City of Cupertino against
I'mbilitics, judgmlo Is, costs and expenses which may in any way recruit against said City
in consequence' fl granting nt this pe it
APPLICANT U DERSTANOS A ILL. COMPLY WI'I'fl AhI. NON -POINT
SOURCE REGULATIONS. •A�• �// /�
n k.,,1..._ {sCs _MoyVk� i�Y/
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or fawn building occupant store or handle hazardous mamdul
as defined by the Cosentino Municipal Code, Chapter 9.12, and the Ifwlth and Safety
Cade, Section 25532(0)9
El Yes E] No
Will the apps icant or future building occupant use equipment nr devices which
sail hazardous air m stuchoants as defined by the Bay Are. Air Quality Management
Doorka?
❑Yes El NO
I have must the haoodous materials requirenmnts under Chapter 6.95 of the Call -
basic Health & Safety Cade. Sections 25505, 25533 end 25534.1 understand Nat if the
building doer not currently have a teams, that it is my responsibility to notify the mcupam
of the requirements which must be met Poor m issuance of a Cenifmum of Occiparal.
PANELS
U P T0200 AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUI UMISC.
'TEMP METER OR POLE INST
POWER DEVICES
SWIMMING POOL ELECTRIC
OITILETS — SWITCHES — FIX'TURIS
NEW RESIDENTIAL. ELF.CTR
PLUMBING PERMIT
PERMIT ISSUANCE
AI TER—DRAIN & VENT— WATCH (EA)
RACK FLOW PROI'EC'I'. DEVICE.
DRAINS— FLOOR, ROOF, AREA, GOND.
I'IXTURIiS — PI7R TRAP
SQ ITT
GAS — EA. SYS TEM- INC.4 (RI1 LETS
GAS— EA. SYSTEM.OVER 4(EA)
GREASFIINDUS1'RL WASTE INf11 RCEPTOR
GREASETRAP
SEWER-SANITARY—STORM IA. 21011 FT
WATER HEATER W/VENTIELECTR
WATER SYSTEM/TREATING
WATIiR SERVICE.
NEW RESIDENTIAL PLMR. SQ17.
TOI'AI.
QTY, MFCHANICAL. PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO Bh(XX) CPM)
AIR HANDLING UNIT (OVER 10,010 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (In 100,001) HE U)
HEATING UNIT (OVER 100,000 BLUE
VENTILATION PAN (SINGLE: RESIDE
BOILER—COMP BLIP OR 1 00,00 BTU)
HOLLER—COMP (OVER I003XXI BTU)
Alit CONDITIONER
NEW RESIDENTIAL MECH. SQ. Fr.
OFFICE
FEE
L
N/C CON 'I40Lk
BUILDING PERMIT INFO
IILDG ELECT PLUMB MEC;
❑ Qr ❑ ❑
JOB UESCRIPTION
RESIDENTIAL:
❑SFDWI.
❑ KII'CHEN REMODEL
❑ADDI'OON
❑PLUMBING RE -PIPE.
❑MULTI -UNIT
C1 STRUCTURAL
MODIFICATION
❑ ISE PRIOR
❑CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
❑ BY] If REMODEIIREPAI
DEMOLITION
❑ M LER
COMMERCIAL:
EI NEW BLDG/ADDITION
❑DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
[]OTHER
jG, Ef. la.(,fARBN
cin 1 tee
FEL? `Urt81/1 0
S1:1
TORIES -I00 xt•e tt
ROUT'
- BUILDING DIVISION FEES
PLANCIIECK FEE
ENERGY FEE
GRAVING FEE
SOBS FEE
PAID
Dote Romiplq
TOTAL:
BUILDING FEE
EEE SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FHE
CONSTRUCTION AS
HOUSING MITIGATION FEE
PAID
Dom Remit, p