B 0310APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
rz6_1 hCc
NAME:
owner Dole
WORKERS COMPENSATION DECLARATION
1 hereby affirm ualer penalty of perjury one m the following collaborate:
]have and will maintain r Certificate of Consent to self-insum for Workers Compen-
sation, as provided for by Section 37M of the Labor Code, for the performance of the
war
'Which this permit is issued.
h ve and will maintain Worker's Compensation Insurance, as required by Section
3700ofthelabor Code, 5Ie perom- cisof the work Ibr which this permis is issued.
My We kpC C Itryen got y)ps})reaes llrter and Pnlicy_py
Conies r CTLiYf�1'0.Y Policy i {'1•C.l `1
CERTIFICATE OF EXEMPTION (ROM WORKERS'
COMPENSATION INSURANCE.
Trhis section need not he completed if the panic is forone hundred dnlbua ($100)
or Icss.7
1 certify that in the performance of the wok far, which Nis permit is itself, l shall
son
not employ any person in any manner so to Became subject the Workers Compcm
Z ..Iran Laws of Califomia. Data
O Applicant I
Cl) NOTICE TO APPLICANT: IL afar making this Cenificme of Exemption, you should
ah become suhjcet to the Worker's Compensation provision of the Lahsr Code, you must
{TI (y tonhwith comply with such provisions or this permit .hall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
L) O 1herehy.M. than the. iso command. lending agency for the perfommnce of
iL F.t the work for which this pernal is issued(Sec. 3097, Civ. C.)
Q Lenders Nnme
U
D.1 Lender's Address
1 1 certify that 1 have mad this application and stare that the above information is
fA correct. ! agate to comply with all city srtd county ordinances and state laws totaling to QTY
U Z building construction, end hereby authorize represc rouses of Nis city to enter upon the
.hove-martioned progeny for inspection Purposes.
(We) ,area or save, indemnify and keep hamiless the City of Cupertino against
liabilities, judgments, costs Ind expenses which may In any way came against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NONPOINT
SOURCE REGULATIONS.
Signatureof ApplicanVCentmcler Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupent store or handle hazardous mamrial
as defined by the Cupertino Municipal Code. Chapter 9.12, and Ne Health and Safety
Code, Section 25532(a)?
❑ Ycs
Will the applicant or butim building circular, use equipment of devices which
ami, haomium; it contaminants as defined by the (lay Area Air Quality Management
District?
❑Ya. �rvn
1 have naJ the Incestuous materials requirements tinder Chapter fi 95 of the Coln
litmiu Health & Safety Code, Se ne 25505, 25533 and 25534. I understand that if the
huilJingA ^^^��P ttyll6yh a cant, thm It k ie, rtspousibility ml) lily the .,.,at
of she requireie I _h try prior rex iscome ofa C<nilicat�/1�fjk�pg
Owner re w m� ilicauV ` (�'�� MOM
vow
(Initial)
ELECTRIC P171ZMIT
PERMIT ISSU CE J
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2k) AMPS
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRGD1q'/MISG
TEMP. METER OR POLE INST. t
POWER DEVICES -
SWIMMING POOL ELECT RIC �1
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECI'R SQFT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOT. AREA, COND.
FIX'1'U RES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
GASB- FA. SYSTEM -OVER 4 LEA)
GREASEJINDUSTRL WASTE INTERCEPTOR
GRLASE'I'RAP
SEWER - SANITARY- STORM G. 200 FT.
WATER BEATER WNENTM.ECTR
WATER SYSTLMlTRHATINO
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,0011 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WMUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE REMD)
BOILER - COMP (3HP OR I(9),Y)(1 BTU)
BOILER - COMP (OVER 100.001) B'N)
AIR CGNDI'I'ONES
NEW RESIDENTIAL MECII. SQ. IT.
OFFICE
s000r 500310
SANTIARY NO. APP .ICATIO SUBM ITAL DATE.
6PO19 `1
u
CONTACT. PHONE:
g'3/ 3�q S 133
❑
yOGO
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66
LICENSED CONTRACTORS DECLARATION
I hereby officer that 1 am licensed under provisions of Chapter 9 (commencing
with Section 9W0)erf Division 3 of NC Busloecsand Professions Code.and my license is
in full hulcered effect. �J'/`
License Cla' I.it.a �a�i-/�
Dale Commcmr_
Qom.
to
y
2824
ARCHITECTS DECLARATION
eeoc
[understood my plonv xbal be used es pnhlic rN
02=1
wit
Y
Licensed Professional
OWNER -BUILDER DECLARATION
C <
fOx. 6 U
Ld O
'41JJJ
1 hereby normal that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requina a permit to ennslnmt, rlmr. improve, demolish, or repair any sincture
prior to its issuance, also ratimms lheapplicnnt lin such Permit to ile a signed statement
the Committees License Low (Chapter 9
ulolhe provisionsof mi
that Ise is licensed Isolated
YQi
W�a0
6 S c
p❑
Ae W �_
(commencing with Section 90001of Division 3 ofthe Businessand Professions Case)or
that he is exempt therefrom and the basis for the alleged exempio r Any violation of
Section 9(131.5 by any applicant for a permit subjecn the applicant m a civil penalty of
t more than Five hundred dollars (5500).
Las owncrof the property, ormy employees with wagesas thciT vole compensation,
will do the work, and am become In not Intendedor an' cold blank, (Site 7144, Business
and Pmmssions Code: TIm Committers License Lew 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 are not intended or affered for
sale. IL havel,ca the building or improvement is sold within one year of completion, the
owner -builder will have the huNen of proving that he did not build or improve for pur-
poso of sola^)`
❑ 1, as owner of the property, am exclusively contracting with licensed contractors if,
ons rm, the project (Sce. 70,L Business and Professions Code:) The Cmdracnr's Li-
u Use does not apply to an owner of property who builds or improves thereon, and
QTY,
who conlmiro for such pmpats with a conmactons) licensed purseanno the Connacturs
License law.
❑ 1 am exempt under Sec. B & P C for this .,at,
owner Dole
WORKERS COMPENSATION DECLARATION
1 hereby affirm ualer penalty of perjury one m the following collaborate:
]have and will maintain r Certificate of Consent to self-insum for Workers Compen-
sation, as provided for by Section 37M of the Labor Code, for the performance of the
war
'Which this permit is issued.
h ve and will maintain Worker's Compensation Insurance, as required by Section
3700ofthelabor Code, 5Ie perom- cisof the work Ibr which this permis is issued.
My We kpC C Itryen got y)ps})reaes llrter and Pnlicy_py
Conies r CTLiYf�1'0.Y Policy i {'1•C.l `1
CERTIFICATE OF EXEMPTION (ROM WORKERS'
COMPENSATION INSURANCE.
Trhis section need not he completed if the panic is forone hundred dnlbua ($100)
or Icss.7
1 certify that in the performance of the wok far, which Nis permit is itself, l shall
son
not employ any person in any manner so to Became subject the Workers Compcm
Z ..Iran Laws of Califomia. Data
O Applicant I
Cl) NOTICE TO APPLICANT: IL afar making this Cenificme of Exemption, you should
ah become suhjcet to the Worker's Compensation provision of the Lahsr Code, you must
{TI (y tonhwith comply with such provisions or this permit .hall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
L) O 1herehy.M. than the. iso command. lending agency for the perfommnce of
iL F.t the work for which this pernal is issued(Sec. 3097, Civ. C.)
Q Lenders Nnme
U
D.1 Lender's Address
1 1 certify that 1 have mad this application and stare that the above information is
fA correct. ! agate to comply with all city srtd county ordinances and state laws totaling to QTY
U Z building construction, end hereby authorize represc rouses of Nis city to enter upon the
.hove-martioned progeny for inspection Purposes.
(We) ,area or save, indemnify and keep hamiless the City of Cupertino against
liabilities, judgments, costs Ind expenses which may In any way came against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NONPOINT
SOURCE REGULATIONS.
Signatureof ApplicanVCentmcler Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupent store or handle hazardous mamrial
as defined by the Cupertino Municipal Code. Chapter 9.12, and Ne Health and Safety
Code, Section 25532(a)?
❑ Ycs
Will the applicant or butim building circular, use equipment of devices which
ami, haomium; it contaminants as defined by the (lay Area Air Quality Management
District?
❑Ya. �rvn
1 have naJ the Incestuous materials requirements tinder Chapter fi 95 of the Coln
litmiu Health & Safety Code, Se ne 25505, 25533 and 25534. I understand that if the
huilJingA ^^^��P ttyll6yh a cant, thm It k ie, rtspousibility ml) lily the .,.,at
of she requireie I _h try prior rex iscome ofa C<nilicat�/1�fjk�pg
Owner re w m� ilicauV ` (�'�� MOM
vow
(Initial)
ELECTRIC P171ZMIT
PERMIT ISSU CE J
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2k) AMPS
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRGD1q'/MISG
TEMP. METER OR POLE INST. t
POWER DEVICES -
SWIMMING POOL ELECT RIC �1
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECI'R SQFT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOT. AREA, COND.
FIX'1'U RES - PER TRAP
GAS - EA. SYSTEM -I INC.4 OUTLETS
GASB- FA. SYSTEM -OVER 4 LEA)
GREASEJINDUSTRL WASTE INTERCEPTOR
GRLASE'I'RAP
SEWER - SANITARY- STORM G. 200 FT.
WATER BEATER WNENTM.ECTR
WATER SYSTLMlTRHATINO
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,0011 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WMUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE REMD)
BOILER - COMP (3HP OR I(9),Y)(1 BTU)
BOILER - COMP (OVER 100.001) B'N)
AIR CGNDI'I'ONES
NEW RESIDENTIAL MECII. SQ. IT.
OFFICE
s000r 500310
SANTIARY NO. APP .ICATIO SUBM ITAL DATE.
6PO19 `1
u
N
FEES
PLANCHECK FEE
ENERGY FEE
GRADING ITS
SOILS FEE
PAID
p
II Date Receipt
[0 'TOTAL:
FEE SEISKIIC FEL
LLECfRIC FEE
ESQ. PT.
I PLUMBING FEE -V,% -h V
MECHANICAL FF. F.
CO NSTRUCTION TAX
I HOUSING MII'IGATION FLIT
ISSUANCE DATE
BLDG ELECT PLUMB 1,1I:1.
❑ ❑ ❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL;
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING REPIPE
❑MULTIUNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOLS
❑ BATH REMODELIREPAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
N
FEES
PLANCHECK FEE
ENERGY FEE
GRADING ITS
SOILS FEE
PAID
p
II Date Receipt
[0 'TOTAL:
FEE SEISKIIC FEL
LLECfRIC FEE
ESQ. PT.
I PLUMBING FEE -V,% -h V
MECHANICAL FF. F.
CO NSTRUCTION TAX
I HOUSING MII'IGATION FLIT
ISSUANCE DATE