S 26501 —
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES- E BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING 1,:1FC`111
BUILDING DIVISION APPLICATION/PERMIT PLUMBIrvr.-nn?cuA
Y181:IR1
I hereby affirm that 1 am licensed under provisions of
al 0 with Section 700(raf Do'nomrJ fthc Busineamdlindaleit�
full
FUO Lim.forc-nd .. •"^".T'�
Fa U V License C ass Ca N
N Q a Date C�mv
CONTRACTOR'S NAME: uc nu.
ADDRESS:,116y NA -110 111 PVV
❑ Consultant Fees Paid by Applicant (Initial)
9 (commencing QTY ELECTRIC PERMIT 17EE
It ory lla'no, is PERMITISSUANCE
APPLIANCES - RESIDENT IAL
an Z 1 undemand my plans shall M used os public me I,
IQi1 Leaned Professional
�J OWNER" BUILDER DECLARATION
Y 6 I hereby arm, the 1 am exempt tram the Carat License Low for the
y Hfollowing reasnn. (Section 7091.5, Business and I'rnfe,ions Coda: Any city In county
which requires a permit to constrva, alter, improve, demolish, or repair any structure
prior to its issuance, also minims the applicant for such permit it) file a signed statement
ythat he is licensed pursuant it) the provisions of the Contractor's License Law (Chapter 9
GE (commencing with Section 700) of Di vision T of the Business and Prat cions Code) or
oy�y that he is exempt therefrom and Ne basis for the alleged exemption. Any violation nl
n LL Section 9011.5 by any applicant for it permit ,objects he applicanno a civil Penalty of
.. not mare than five hundred Jollura ($5(X).
SpQ ❑ I, as owner ofthe property or my employees with wag% as their sole esmparsedi n,
will do the work and the structure is not intended orolfered for sale (Sm. 7144, Business
3 and Prol'wsamn Code. The Contractor's Licenac Law does not apply to an owner of
progeny who builds or improves thereon, and who doe+such work himself or through
his own employees, provided that such improvements am not intended or offered for
sale. IL however, the building or improvement is sold within one year ofeumpletion, the
wnerhuilder will have the burden of proving that he did not build or improve for pnr-
pase ofwle.).
❑ L as owner of the property, am exclusively cummcting with licensed rommcen m
construct the project (Sec. 9194, Business and Professions Ca1c:)'I he Contracer'a Ia-
cense Law does not apply to an owner of progeny who hail&, or itnproves thereon, and QTY.
who contracts for such projects with a conwcegs) licensed p uxuant In the Contmerors
License Law.
❑ I am esearm under Sec. B & P Clair this mason
Owner Dam
WORK ER:$COM of perm, on DECLARA'T'ION
I hereby off rte under Certify of one of the following declarations
❑ I have and will maintain a Certificate
ion 3700 of the Lab urCod i, for
for Workers ce or th-
sntian, to provideA fist by Section 791X1 of the Labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Warker s Compensation Insurance, as ""brill by Section
of the Inbar Cade, for theperfonearm of the work for which this pemoit is issued.
,asst
My Worker' C m I jtr and Pnlicy n m
Cartier. Worker' 1nD'bPolicy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This smtimn need not becomplemd tithe permit is forms, hand ec dollen ($1(XB
or lc,,,)
I coni fy that in the Ledo mance of the work for which this permit is issued, l sholl
not employ any Earn. in any manner sa as In bene object at the Wakeri Compete
O z senor La f Califs iu. P t
z Applicm
NOI'ICII TO 'LICAN'I': IL after making this Cenllica a of Exemption, you should
(-' become subject to the Workers Consternation provisions of the Lsbor Cola you most
Wfanhwithcndplywith mchpmvmisro rlhis permirshallbeirmanedremked.
Q
CONS mi..rRUC,
o..UiNDINGAGISNCY
UO lfothereby
whic Irradiation d¢rei,sued(Sm..i30 len Jing agency for rhe Eerfnnnana rf
W H the Work for which this Ecnnit is issued (Sec. Jf19T, Civ. CJ
0 U Lenders Nmnc
} as lender s Address
rFas rtee, the 1 have read da,applicationand camp madmithe diva Nat the above automation relating is
.o EyEZ cancel. building construction,
agree comply and landbyl ntyend rnumyardvca of this
sere laws relating to QTY.
U z building conmm�ion, and hereby authorize representatives o(this city mattrition the
above-memimmal propcny for inspection ptu '
(We) agree tit indemnity and keep hamiless the City of Cupertino against
Iiahilitles,pid'ourns.c msoodespenseswhichour, in any way neem, agalns"tell City
inconvatruenceofth ruiningmNispemtit.
APPLICANT U .RS r - ND W MI'I WITH ALL NON -POINT
SOURCB RF Tlf
Sign of Appllcam Contractor Doc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ar future building occupant store or handle hamNoas malarial
as defined by the Calandra Municipal Cole, Chaplar 9.12, and the Health and Safety
Cade, Seen.... 25532m)f
Cl Yes
Will the apPlicmn nr future building occupant use equipment or devices which
mil hvadous air cnnmminam, as derided by the Bay Area Air Quality Management
Oil Deal
Diaries?
El yes Nn
1 have mad the hazardous malarias requurnamo s under Chapter 6.95 of the Cali.
fomia Health & Safety Cattle, Sections 25585, 25533 and 15574. I understood and HOW
building does not comedy have a,nam,,hist it is on, responsibility to amity the occupant
of the mquir nems which man Fev7xefpdor m�eSeynec of a Cenilkmeof O...prne,
PANELS
UP TO 200 AMPS
SIGNS ELECTRiCN.
SPECIAL CIRCUITIMISC.
'I EMP. MITER OR POLE INST.
POWER DEVICES
SWIMMING POOL. ELECTRIC
OUTLETS -SWITCHES - FIXTURES
NEW RESIDENTIAL ELECT R
PLUMBING PERMIT
PHRMI"1'ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, CONIC.
FIX TURES - PER TRAP
GAS - EA. SYSTEM -1 INC.4 OUTLETS
GAS -IIA. SYSTEM -OV ER 4 (EA)
GREASPII NDUSTRL WAS TE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - S I ORM EA. 200 FT.
WATER HEATER W/VEWE LECI'R
WATER SYSTFEAO HEATING
WATER SERVICE
NEW RESIDENT JAL PLMB. SQ. IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MFCI1.
AIR HANDLING UNIT (TO MORE CFM)
AIR IIANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD PV/DUCT)
HEATING UNIT (TO 101,000 BTU)
HEATING UNIT (OVER I00,00 BTU)
VEST ELATION PAN (SINGLE RR.SID)
BOILER -COMP CUP OR 100,0X1 BTU)
BOILER -COMP (OVER 100,1X1(1 tlTlll
AIR CONDITIONER
NEW RESIDENTIAL MITCH. SQ. FT.
FEE
S 2650
NITARY NO. APPLICATION SUBMI^TTT
NICAL
/T I
CO OL# NT
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ X ❑
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL.
❑ADDITION
Fl PLUMBING RE -PIPE
❑MULTI -UNIT
[_1 STRUCTURAL
MODIFICATION
❑INTERIOR
[I CHIMNEY REPAIR
IMPROVEMENT
❑SWIMMINGPOOLS
❑ BATH REMODEUREPAIR
❑ DEMOLITION
❑ rHER
qn
COMMERCIAL:
❑ NEW 'BLDG/ADDITION
[I DEMOLITION
C3 TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT FLOOR AREA I $/SQ. FT,
STORIES 11 TYPECONSTRUCTIOb
BUILDING DIVISION ITES
PLANCHECK FEE
ENERGY FEF.
GRADING FEE
SOILS FEE
PAID)
(late _Receipt#
'IJ•t�
TOT;L(•
BUILDING ITE
FEE SEISMICIgiR J~ Ale
I
ELECTRIC FEE
PLUMBING F', C?V
MECHANICAL FEIi
CONSTRUCTION TAX
HOUSING MITIGA ON PEE
L&
PAID
DPISS
ipt#TO L:E DATE ?