29485APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
� BUILDING DIVISION' APPLICATION/PERMIT PLUMBING - MECHANICALNR I . 29485
Billy 7lyVVrllRr"1' I IIIr.NTI1IsoxTn1N
❑ Consultant Fees Paid by Applicant (Initial)
I hereby afl'orm that 1 nm licensed model provisions of Clmpmr 9 (a marine,
with Section 7001) of Division 3 of the Business and Professions Code, and my license is
in full force and eRccl.
License Class Lick
Dole Commrcbb
ARCHITECT'S DECLARATION s
I underslanJ my plans shall h used ns public rtcoNs I
Licensed Professional
OWNER -BUILDER IIECLARA'I'[ON
1 hereby affirm that 1 am exempt from the Carlini License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any airy be county
which requires or permol to construct, ahe9 improve, demolish, no repair any Nmcmre
prior to it issuance, also requires the applicant for such penniuo File or signed statement
that he is Resoled pursuant o the provisions ol'the Conuucmrs License law (Chapter 9
(commencing with Section 70(1) of Civilian 3 of the Business it Professions Code) or
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 applformal to a civil penally of
not more Non five hundred dollars Si
❑ 1, as owner of thatpe"myor no, employers with wages us tildesole annpenaafor.
will do the work, and the structure is not intended oroffered for sale (Sec. 7094, Business
and Professions Code: The Comment's License law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or Through
his own employees, provided thill such improvements are mol intended or offered for
I.E. If, however, the building or improvement is sold within one year of comply inn, the
owner -builder will have the burden of proving that he did not build or improve for pur-
Inse of sale.).
1, as owner of the property, am xclusively contracting with licensed contractors to
cons11Le1 the project (Sew. 7044, Business and Perfesdons Codc:) The Contractor's Li-
canse Law does nor apply to an owner of property who Istri Ids or ityprovei, thereon, and CITYwho contmets for such projects with a contmctim a) licensed pursuauthe e Contractors
License law.
O IameaempJtnder Sec. _,B&PCforthisyeasoa
1 h<rtby affirm under penally of perjury one wf the following declarations:
polo 1 have ands, ill maintain a Certificate of Consent o self -i allow for Worker's Compem
salary, you provided 0n by Section 37N of the Labor Calc, faille performance of the
work for which Nis permit is issued,
❑ 1 have and will maintain W'orker's Compensation Insurance, as railroad by Section
3700 of Ne laborCnls, for the performance oflhe work for which this pevnit is issmad.
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy Nn:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the Penley is forms hundred dollam ($100)
or less,)
I Goo thin in the perform colnt the walk for which this permit is issued. Ishall
mol employ any person in any manner so as to become straps o the Worker,' Comply -
z sation laws of California. Done.
7�7 0 Applicant
Imo— N NOTICE APPLICANT: IL attar making this Certificate of Exemption, you should
become subjhp ect by the Workers Cntitpcor this
pmvislhut metiredoe Labor Cale, you must
L7) fmnhwitll comply wish such pmvisinns or this pemlit shall N: Deemed rcvokeA.
Q
QaP. CONSTRUCTION LENDINGAGENCY
.1 I herebykfillw vffirnmhanhert lsamn(Sec.1nlending agency lirnha performmrre of
w the work fill whitll this permit is issued (Sec. 71197, Civ. Cd
Q U Lenders Name
Lenders Address
y 1 certify that 1 have read this application and state that the above information is
.r IA con'eon. I agree to comply with all city and county ordhmnces and Nate laws relating to QTV.
U buiWingeonswclion, an hereby uwhonze reprexenfutives nflhls citymenmr upon the
above-mentlonad property for inspection puUroves.
(We) agree to save, indemnify and keep hmtnless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way acetas agvinn said Cory
a. consequence of the gaming.1 Pili, permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONFPOINT
IIAZ RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardoua material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)Y
[I Yes FNo
lift
Will Ne applkan, or future building occupant use equipmnt eor devices which
coir hazardous air contaminants as defined by the Bay Area Air Quality Management
D'alrict7
`❑Yee []Nn
I have read the hauNous materials requiremenu badly Chapter 6.95 of the Cori -
in flealN & Safely Cade, Sections 25505, 25.533 and 25534. 1 understand that if the
11 try ng fees not currently have or least that it May mspnnslbl lily to, nmify the occupant
of the mquiremenls which must he met prior to issuance of a Cenifcare of Occuponcy.
ELI?CTRICPERMIT ITE
PERM) F ISSUANCE
APPLIANCES — RESIDENTIAL.
PANELS
UPTO200AMPS l_
SIGNS ELECTRICAL.
SPECIAL. CIRCUIT/MISC.
TEMP. MITER OR NILE INS'1'.
POWER DEVICES
SWIMMING POOL ELECTRIC
OLITLEI'S — SWITCHES — FIXTURES
NEW RESIDENTIAL. F.LECfR SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER — DRAIN as VENT— WR'I'ER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF, AREA. COND.
FIXTURIES — PER TRAP t
GAS — EA. SYSTEM -I INC. 4 OUTLETS
GAS -2A. SYSTEM OVER 4 (EA)
GREASMNDUSTRi. WASTE INTERCEPTOR
GREASETRAP
SEWER—SANITARY—STORM EA. 200 IT.
WATER IIEATER WNENT/ELF.CI'R
WATER SYSTEMITREATING
NEW RESIDENTIAL. PLMB. SQ, Ief.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD'1'O MECH.
AIR IIANDLING UNIT LTO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXI1AUSPHOOD (W/DUCT)
HEATING UNIT ('1'0 100.010 BTLE
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RfSID)
BOILER—COMP QHP OR 100,001 RTU)
ROILHR— COMP (OVER IBB,(NIB RTI3)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. ff.
OFFICE
NIC CON'I'ROLN
BUILDING PERMITINFO
3LDG ELEC3i1 PLUMB MECH
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL,
OSFDWL
O KITCHEN REMODEL.
❑ADDITION
O PLUMBING RE.PIPH
❑MULTI -UNIT
El STRUCTURAL
MODIFICATION
C1 INTERIOR
11 CHIMNEY REPAIR
IMPROVEMENT
O BATH RHMODELJRIiP O DLMO ON
C3 OTHER 1��
�'1�1
❑NEW BLDG/ADDITION ❑DEMOLITION
OTENANT ❑ FOOD SERVICE
IMPROVEMENT
O OTHER
KY
Far: NlAR 19 ig
G1 Y ur lurk.
BUILDING DIVISION FEES
I' ANCHECK PER
ERGY FEE
GRADING PER —1
SOILS FEE
PAID
Ilam Recalls, M.
BUILDING FEE
PIER SIiISMIC FEL
ELLCfRIC FRE
A L
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Data Reacy,IF
TOTAL.:
ISSUANCE DATE