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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE
CITY OF CUPF,RTINO
BUILDING DIVISION APPLICATIONIPERMIT
ILDINGADDBMS:
BU
115 V l 4 Ph ISO . eq pG 2Tmjb .
reher No 98 s Gay{ 8
LICENSED CONTRACTOR'S DECIARATION
1 hereby affirm shat 1 am licensed under pmvi,ama of Chupmv 9 (commencing
with Section]000) ofDivision 3 ofthe Businessand Pmfesamrn Gyle,and my license is
in full force and effect.
License Class Lie.»
Date _ Contactor
ARCHITECTS DECLA RATION
1 understand my plans shall he used as public hounds
POINT PEN ONLY
pls113MINHE
❑ Consultant Fees Paid by Applicant (Initial)
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 um exempt from the Contractors License Law for the
following reason. (Section 1031.5, Business and Professions Code: Any city or county
which trapdoors a permit to consumes, alter, improve, demolish, or repair any structure
prior to its issuance, also minutes the applicant for such Permit to file a signed statement
Net he is licensed Panama to the provisions of she CmdracrMs License Law (Chapter 9
(commencing with Sect ion 7") of Division 3 of the Business and Professions Code) (it
that he is exempt therefrom and the basin for the alleged exemption. Any violation of
Section 1831.5 by any applicant for a permit subjects the applicant to a civil penalty of
not room than five hundred della. ($501
❑ Las owner lithe progeny, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 1014, Business
had Professions Cade: The Contractor's Licensc Law does no, apply m au owner of
property who builds or improves thereon, and who does such work himself or through
his own employees. Provided that such improvements sm not intended or offered for
sale. IL however, the building or improvement is sold within one year of completion, the
owneolmilder will have the burden of proving that he did not build or improve for put.
p se of sale.).
❑ 1, as ow, net of the property, int exclusively contracting with licensed contractors to
construct the pmjecs (Sec, 700. Business std Professions Cade:) The Contractors U.
cense law does not apply m an owner of property who builds or improves therepn, and QTY,
who contracts for such projects with a contracmds) licensed purmanuo the Contractors
License Law.
C I am exempt under Sec. ,B& P C for this reason
er Date
WOR KERS COMPENSATION DECLARATION
1 hereby affordunder penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen
salon, as provided for by Section 3100 of the tabor Code, for she performance of the
wook for which his permit is issued,
❑ I have and will maintain Worker's Compensation Insurance, d required by Scene.
.3100 of the Labor Cdde, for the Performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy Nn:
CERTIFICATE OF EXPMPf10N FROM WORKERS'
COMPENSATION INSURANCE
("is section need not be completed iftbe permit is for one hundred dollars IS 100)
orle,e.) I
1 verify that in the performance of the work for which this permit is issued, l shall
not employ any gservar in any compo oro as to become subject to to Workers Compen
smion Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, utter making this Ctmileam of Exemption, you should
became subject to the Worker's Compensation provisions of the Lpbnr Code, you must
forthwith comply with such provisions or this permit shall b, deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance or
'the work for which this permit is issued (Sec. 3091, Civ. C.)
Lender's Name
Lenders Address
1 certify that I have read this application and state that the above information is
correct. l agree to comply with all city emit county ordinances and nate laws relating m QTY,
building construction, and hereby authorize representatives of this city to enter upon the
alwve-mentioned property far inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments costs and expense, which may in any way same against sold City
in untscqucnce of the Staining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE I�6ATIf NS.
--fnA/ 4 ~q 7
Signetm'c f Appllc tJCont acmr 4 Date
HAZARDOUSIMATERIALS DISCLOSURE
Wi11 the applicant or Municipal
e, Chapter
handle hazardous material
as defined by the Cupeninu Municipal Code, Chepmr 9.12, and the Health and Safety
Coda, Section 25532(a)'1
❑Yes C] No
Will the applicant nr future building ceoupant use equipment or devices which
us hazardous it cnnrnminants as defined by the Bay Area Air Quality Management
District?
❑Yes E3 No
I have rend the hazardous materials requirements under Chapter 6 95 of the Cali.
fomia Health & Safety Code, Sections 25585, 25533 and 25534.1 to de.mnd that if the
building does net currently have a tenant, that it is my responsibility m notify the occupant
of the t�iryments w�yh must he met prior to issoancc of a Cenficute of Occup fy,
ELECTRIC PERMIT FF,E
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL.
PANELS
UP TO 2M AMPS
SIGNS
TEMP. METER
POWER DEV0
SWIMMING P/
NEW RESIDEGftALELEC7i[j_4,. SQFT.
PLUMBING PERMIT I FEE
& VENT— WATER (EA)
2TECT. DEVICE
T�
d. ROOF, AREA. COND.
Lk -1
IN]
JOB DESCRIPTION
'
RESIDENTIAL:
CSFDWL
C KITCHEN REMODEL
❑ADDITION
11 PLUMBING RE -PIPE
.0 MULTI -UNIT
❑STRUCTURAL
PLANCHECK ' O
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
WATER SYS 'THM TREATING
❑BATH RBA IY
❑ i(�IJA
COTHER
NEW RESIDENTIAL PLMB. SQ. IT.
144Mdul'orgm
COMMERCIAL:
CNEWBLDG/ADDITION
_n
'
❑DEMOLITION
[]TENANT
❑ FOOD SERVICE
IMPROVEMENT
SEISMIC FEE
[]OTHER
Ii1.F.CfRIC FEE
SQ. PE FLOOR AREA I StSQ. FT.
amlJ
GAS —EA. N9THM-I INC.4 OUTLETS
OCC. GROUP
GAS — EA. SYSTEM -OVER 4 (FA)
GREASEIINDUSTRL WASTE INTERCEPTOR
RUI DING DIV/ION F
GREASE TRAP
PLANCHECK ' O
SEWER—SANITARY—STORM EA.20o FT.
DNERGV
WATER HEATER WNENTICLECfR
GRAIN
WATER SYS 'THM TREATING
SOI S E
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. IT.
Dam Rcccipt»
TOTAL
TOTAL:
BUILDING H
MECHANICALPF.RMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
Ii1.F.CfRIC FEE
ALTER OR ADD T'O MECIL
PLUMBING FEE
AIR HANDLING UNIT(TO I0,000 CFM)
MECHANICAL FE'
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCf1ONTX
Is.XHADB3'IIDDD (W/DUC31
HOUSING MITIGATI NFRH
HEATING UNIT (TO Ustogg tl'flf)
HEATING UND (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER —COMP (3HP OR 100.000 BTU)
BOILER — COMP (OVER 100.008 BTU)
AIR CONDITIONER
NEWRESIDENTIALMECH. SQ. FT.
PAID
Date
ISSUANCE DATE
I ISSUED BY:
OFFICE -- -