30854APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL,- I PERMFr NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PRDIP.Cr IDENTIFICATION
:1,6P 7r�
NDN J a4TA Lee P
CONTACT: PHONE:
" M I WLPl 4.1& &538&
LIC NO:
❑ Consultant Fees Paid by Applicant (Initial)'
1 hereby affirm that 1 am licensed under pocviAm s of Chapter 9 Monmtencing I t
HOZ with tio
Secn700McfDisision3ufate[3u&ines&aad Professions CodebmI my license is
F W in full ancestral effect, t
QUZ U License Class ' Uc. a
hg.Q�1 Datil Corrector OZ -ARCHITECTS DECLARATION
1 understand my plums,hall be ureco
sed as public recon,
ad,
41 Licensed Professional
tilN',G�.•�..11 OWNER -BUILDER DECLARATION
yey OC yy22 1 hereby .]film abut I am exempt from the Contractors License Law for the
pd 36 L) following reason. (Section 7031,5, Business and Professions Code: Any city or county
LL y , which requires a permit to eonsuuct, alter• improve, demolish, or rcpdr my summre
m pilar to its iss men,ince reaches he applicant for such permiuo file u signed statement
<� that he is licensed pars ant or me provisionsofthe Contractors License Law(Chnptar9
�0 (commencing with Soothed 7000)ef Division 3 oT the Business and Profession, Code)o,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil Penalty of
p, p. ]room than five hundred dollars($500).
x� 6 ❑ 1, as owner of the property, or my employees with wages as their sole compensation,
(..� will do the work. and the Structure is not intended of olievd formic (Site 7(N,I, Business
3 and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees provided that such improvements arc not intended or offered for
Stile. If, however, the building or improvement is sold within one year of completion, me
owner -builder will have the burden of proving that he did not build or improve for pun
from of sale)`
EI 1. as owner nl the ,.Pont,Pin exclusively commenting with licensed commemrs m
construct the project (Sec, 7M4, Business and Professions Calc:) The Contractor's Lt.
c m law does not apply to on owner of pmperly who builds or improves thereon, and Qj'y.
who contracts for such projects with a contmdor(s) licensed pursuant o the Contracmts
U..... law.
❑ I .,it exempt under Sec. ,B& P C rill this lean..
•Owner hate
WORKER'S COMPENSATION DECLARA'T'ION
1 hereby affrn under penalty of perjury one of the
❑ declare"
e m
Ihuve and will mainmin aCenlBam nfConsenue salGireareforWorkin",Com
pen-
wtion, as hick In,
n for by S, issued. of the Labor Cnde, for Ne perintmnnce of the
work lin which thi&�parmit L ixsued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3900 of the Labor Coda, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance cancer and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed for, permit is fnramchumlred dollars (5100)
or lea.)
I certify that in the pvrmommmce of the work I'ar which this permit is issued, I &hall
not employ any person in any manner so m to become subject to the Workeri Compen-
0 z motion laws of California. Dam
z Applicant
.� NOTICE TO APPLICANT': If, afar snaking this Certificate of Exemption. you should
abecome subject to the Workers Cnnapensanlon poo, does of the Labor Code, you matt
Wforthwith comply withouch Provisions or this permit shall be, deemed revoked.
Q
z CONSTRUCTION LENDING AGENCY
U 0 1 herebyaffirm thin the. iso constractim. hading.gency lot he perfunm.neeol'
Lt. !^ the work for which this permit is issued (Ser. 3199, Civ. C.)
0 U Lenders No.
yLenders Address
0. 1 certify that 1 have read this application and state that the drove information is
CO; come[. i agree it) re
comply with all city and emoryordirances and state laws baing to QTy
U7
G building construction, and hereby authorize representatives ofthis city rr enter upon the
drove-memmned property for inspection Pmpeses.
(We) agree to mve, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue option said City
in em sequence of Ne granting of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULA'T'IONS. I
HAZARDOUS MATERIALS DISCLOSURE
Will are uppliwnt or futurebuilding occupant snort or handle hazuNnus material
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Health and Safety
Code, Section 255321.)1
❑Yes E] No
Will the upplleant or future building occupant use equipment or devices which
mit h.aallous it conwmimpas as defined by the Bay Area Air Quality M ... gement
Dwt i.rl
El yes C] No
- 1 have mad, the h u,minds ratio requirements under Chapter 695 of the Coal.
forms Health & Sfety Code, Sections 25505.25533 and 25534. 1 understand that if the
building does not cut ently have a tenant, that it is nay responsibil lty to and fy the occupant
of me requirements which must be met prier to issuance of Certificate of Company.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2EU AMPS
OVER
BUILDING PERMIT
LElKITCHEN
REMODEL
ALTER - DRAIN & VENT- WATER (EA,
TION
ElPLUMBING RE -PIPE
❑DEMOLITION
❑FOODSERVICE "
TI -UNIT
TUL
❑STRUCTURAL
OUTLETS -SWITCHES -FIXTURES
GAS - EA. SYSTEM -OVER 4 (EA)
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT'
'ENERGY FES Ii
R
❑ BATH REMODEUREPAIR ❑DEMOLITION
OOTHER
$/SQ. 17L
s e
SPECIAL CIRa'I'/MISC.
APR 1 Q Mtn
VALUATION
CICL1r-, WGKINU
V ILS s.W
ALTER - DRAIN & VENT- WATER (EA,
T'EMI'.MEFEROR I't N
COMMERCIAL
❑NEW BLDG/ADDRION
❑NANT
OVEMENT
❑
❑DEMOLITION
❑FOODSERVICE "
POWER DEVIL'
SWIMMING POOL F;LEC'MIC
OUTLETS -SWITCHES -FIXTURES
GAS - EA. SYSTEM -OVER 4 (EA)
GRI'ASE'INDUS1'I<LWASTHINIERCEPTOR
NEW RESIDENTIAL ELECR SQ FI'.
'
SEWER - SANITARY - STORM EA. 2W Fr.
'ENERGY FES Ii
R
SQ. FT FLOOR AREA
q 66 0
P A I D
GRADIN FE
$/SQ. 17L
s e
PLUMBING PERMIT I FEE
PERMIT ISSUANCE
APR 1 Q Mtn
VALUATION
CICL1r-, WGKINU
V ILS s.W
ALTER - DRAIN & VENT- WATER (EA,
BACK FLOW PROTECT DEVICE,
DRAINS- FLOOR, ROOR AREA, COND.
STORIES
DEC. GROUP
TYPE CONSfI
APN
FIXTURES - PER TRAP
GAS -EA.SYSTEM-I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GRI'ASE'INDUS1'I<LWASTHINIERCEPTOR
E^qJJ'DIVISION FEES
PLANCHECK PEE JA �e�
GREASE 'I'RAI'
SEWER - SANITARY - STORM EA. 2W Fr.
'ENERGY FES Ii
R
WATER IIEATER W/VENT/ELEMR
GRADIN FE
WATER SYSHMO*REA'FING
s e
WATERSERVICE
PA - ,.
NEW RESIDENTIAL PLMU SQ. Fr.
MECHANICALPERMIT
FEE
BUILDING FEE
Ll
51315MIC FEE 51,
'
PERMIT ISSUANCE
LILECTRIC FEE
PLUMBING FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10," CFM)
MECHANICAL IM
AIR HANDLING UNIT (OVER 10.000 CFM)
CONSTRI NTAX
EXHAUST HOOD(W/DUC)
HOUSING I'1'IGATION FEE
HEATING UNIT (TO 100,000 BTU)
-
HEATING UNIT ((OVER 100,0011 BTU)
PAID
Date
l'O
VUJ'GLA'I']ON FAN (SINGLE RESID)
BOILER -COMP LIHF OR 100,000 BTU)
BOILER -COMP (OVER 10U.000 BTU)
NEWRESIDE- IALMECIL Z SQ. for,
OFFICE