S 0685F-
I W
Y
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ DUE 1)INC-ELECT RICA PI:RMU No
BUILDINGDIVISION APPLICATIONA'FRMI'pr rvrvr.UM'xm(rnrSa rr,alwr r .r1 S O 0 S 5
_ r �aTtns
LIC NO:
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONfRAC OR'S DCCV,RATION
I hereby affirm that lain licensed under provision%of Ch.pte 9 (commencing
Z=Zwish Session 7") of Division 3 of the Business and Pmfa,dons CWl and my license ie
40
�, 2 In full force and strict.
RU~License Claxe_ Lie.a
n Q a Dam Conummr
_U,n ARCHITECT'S DECLARATION
Z= Z 1 understand my plans shall W used as public reeoN%
nf" Liccn¢d Professional
OWN Pit BGELLER DECLARATION
Ow< 1 hereby anion that 1 um xempt from the Contractor'% License Law for the
yU following ma h. Sectien)IUL5 cs
lluvincr and NoE..ian, Code Any uayo county
ywhich revuimx a peril, ,, amurpm, aou.improve, demolish, or repair any ,micame
CQ poor to Lx assua.oc.,Iao«quims the applicant lot shah permit m file aognedxwtenmnl
yTJ rant that he is licensed pumato the prow ,of the Contractors License Law (Chuprer9
W=GAO (commencing with Seelli 700(nofDoi ..On3otthe[so ,tnca and Profexsmns Crddnr
Z eI 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 to. civil panulty of
t more than f sac hundmd dollars (5585).
EZD ❑ I, as owner of the property, or my employees will, wages as their sole ahmpcnsalion.
p. wi lido the work. and rhe.strucmre isnot i ntended ornRaaJ for .are (Set, 7344. ifu.incs.
1'3 m and Prol'ce,iom Code: The Contractor's License Law does not apply to an owner of
propcny who builds or improves thereon, ;and who docs such wore himself (it through
his own employees, provided that such improvements are not intended or offered for
,.It. If, M1nwevs+, the building or itomolommot is sold within one year of cnn.pl,don, the
ovarm,lbuildc, win have H
the burden of pmng Ill.,fn
be did not build or improve s per-
poof "ale).
0 I, as owner of the prof on um exclusively contracting with licemel contractors to
emvom, he pohjue (Set. 7044, Bnsinox and Pmbh "ions Ctdc:)'1'Ile Contractors L. -
twe Law does not apply to an owner of pmpertY who builds or improves thereon, and
who contracts forxuch project with a conte s) Iicenottd poismen tan the Contractors
Lice se l:mw.
❑ I am escropi under Sec. . B & 1' C for this reason
Owner Dote
WORKERS COMPENSATION DECLARATION
1 amity affirm under penalty of perjuryone of the following declararlons:
O 1 have and will orinaina CcnifimtcnfGm..a, to xcli� irunrc for Worker's Cnanpun
•.inn, as provided for by Section 37M of the Ivbor Code, for the Icrfonnancc of the
wok for which thG,,snit is.....il.
0 1 hale not will maintain Worker's Compensation Insurance. as respired by Section
37(X) of the LuhorCode. for the performance of the work for which Nis rennit is iavaed,
My Wmkces Compensation Insurance carrier and Policy number are:
Canino Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
CONIPENSAIION INSURANCE
(Thi, semen sed not be completed ifthe permit is formic hundred dollars (MCMI)
orlpa.)
I certify Ihm in the IerfamwneC of the work for which This pemoo is i,.weit, l ,hall
not employ any person in any manner no as to become subject to the Worker Compen-
Z union Laws of Califon ia. Date
zO Applicant
r y NO ICETO APPI.ICAN'1. If, Harr, making 1111S CCnI➢cate of I?xrnhpl on. you should
a ; become subject to the Workers Compensation prevision, of the Labor CWe. you must
forthwith comply with such provi icns orchis permit %hall Ise deo ned revoked.
U0 GONSem is ac0NLENDINGn agency
U p I hereby affirm thatthemissued(Set.N lending agency fonhe performance of
U. F the work for wM1lch this penin is issued (See.38)9, Civ. CJ
0U de
Lenders Name
%' UILE Lenr's Addmxs
I cenify that I have read Ihn application and state that the above information is
conal. 1 ogme Rh amply with all city and county ordinances and state laws relating in QTY.
U Z building construction, and hershy amhoriac mprcoadatives of Ilii, city to enter uponthc
above mentioned property lin inspection purposes.
(We) agree mime, indemnify and keep hnmdess the City of Cupatl.o ngaimt
liabilities. judgments, cast%and expeme. w hich may in any way amrvC against said City
-
hnxequence of the granting of TMs permil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicaMCmnracmr Date
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occ.pion mom or handle hmmdota material
.a.s defined by the Culcrlim Municipal Code, Chapter 9.12, and the Ilealth and Safety
Code, Section 25532(x)?
❑Ye, ONit
''\ Will the applicant or future building occupier use equipment or device.., which
nn bumnloux air cnnmminantx as defined by he Buy Area Air Quality Mnnngemmct
District!
(]Yrs No
I have rad We havpNou, maarials iequiremems under Chapter 0.95 or (lie Cali
form. Heath & Safety Cak, Sections 25505.25533 mW 25534.1 understand ohm if The
build; ng docs urn com nd, have a mount, that it is my responsibility to notify the mccup.nt
of the n,rommcnm which most be mar prior to issuance Oct. Comficree of Occupancy.
ELECTRIC PERMIT
PHRMH ISSUANCE
APPLIANCES - BESIDE, IAL
PANELS
UP TO BMl AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M
TEMP. MtETElit OR P)- .T.
POWER DEVICES
SWIMMING POOL ELECIRIC
OUTLELS - S W IT C H EY - I9 XTU RES
NEW RESIDENTIAL ELFCI'R
PLUMBING PERMIT
PEI1M1'1' ISSUANCE
ACIIiR- DRAIN & VI!Nr- WATER (I;AI
HACK FLOW PROFEC'1'. DEVICE
DRAINS - FLOOR. ROOK AREA. COND.
FI X'IURES- PER'Ifbj �
GAS-EA.SYSTI! -
GAS-EA.SYS'FEN{vFR44E4Vn I
SQ FT.
I:UI
SQ. FE FLOOR AREA
FEE
S"TORIES
GRIiAM?TRAP
❑
V w
BUILDING PERMIT INFO
BLDG EL!C9PLUMB MECH
1-04 ask Ilk S
WATER IIEAI'12R WOVEN UFI.EC'I R
FEE
JOB DESCRIPTION
RESIDENTIAL:
UW'L ❑ KITCHEN REMODEL
ADDITION C3 PLUMBING RE -PIPE.
❑MULTLUNIT ❑S'I RUC'IURAL
MODIFICATION
C IN'IIPRIOR EI CHIMNEY REPAIR
IMPROVEMENT [I SWIMMING POOLS
O BATH RE IODFUREPAIR E3 DEMOLITION
0 (TITTER
WA'I HR SYSTEM11 REAPING
SOUS ITdE
WATER SERVICE
PAID
DI" eeipr X
COMMERCIAL:
[I NEW BI.DG/ADDITION ODEMOI.I'I'ION
O TENA NT ❑ FOOD SERVICE
IMPROVEMENT
❑ (OTHER
TOTAL
SQ. FE FLOOR AREA
FEE
S"TORIES
GRIiAM?TRAP
PLANCK IEE
$FIWEN-SANT I'AR IFI'.
ENERGY '
WATER IIEAI'12R WOVEN UFI.EC'I R
clMnlnuc Flan
WA'I HR SYSTEM11 REAPING
SOUS ITdE
WATER SERVICE
PAID
DI" eeipr X
NI?W RESIDENTIAL PLMB. SQ. Er
TOTAL
Lt
BUILDING FHE.
MECHANICAL PERMIT
FEE
SEISMIC IFI: Era% Es
PERMIT ISSUANCE
ELECTRIC FEE V7
ZIA
ALTER OR ADD TO MECH.
PLUMBING FIE
AIR HANDLING UNIT (TO I O,0(X) CLOD
MECHANICAL FIDT
AIR HANDLING UNIT (OVER 10.00O CFM)
CONS'FRUCTION'1'AN
EXHAUST HOOD (W/DUCD
Hous NG MI'IIGAfION PE
BEATING UNIT GO 10)(LO X) BTU)
HEATING UNIT (OVER 100.000 B'IU)
PAID
Utile Rettipl M
VENTILATION PAN (SINGLE RESID)
BOILER -COMP GI IP (1R I(X)(X)0 ETU)
TOTAL:
BOILER - COMP(OVER I(M)IM)BBTU)
AIR CONDITIONER
Is`s�1unncF: DATE
2� / .-,
ISSUIiU HY: �/ Is
O
NEW RESIDENTIAL WICIL SQ t•T
OFFICE