B 0329APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION
BUILDING. ELECTRICAL
APPLICATIONWERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
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P13RMI I NO. ~ 0 3 2 9
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BUILDING ADDRESS:
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ES-FH�s 17� -
SANITARY NO.
APPLICATION SUBM[ FI'AL DATE
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OWNER'S NAME:
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PHONE:
(] SWIMMING POOLS
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CONT IYBLtS NAM LIC NO:
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I I ECT/ENGINEU R fIC NO
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CONTACT:
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❑Consultant Fees Paid by Applicant (Initial)
13UILDING PER MIT INFO
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ELECT PLUntI� hf r
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1 hereby aton but 1 anlicensed order provisions of Chapter 9 (commencing
pZ with Section 7")of Division 3 ofthe nosiness and Pmfeszinnc C9�,and my licenm is
UO in fill fiimc anJc het. 4b�- 'j /Le ;W
FI License Class Lic.9 / —`
ZOrnZ lunderaundm a h used asp 6➢c rcna'/'� tr rP
OZ rte- ons
F 4117 W Electoral lsmb,s,am '
�y i; OWN( ER U:CLARA
C ¢1 Q 1 M1ereby anion rho 1 m
exempt
from the Comramors Licenss Ise for the
OW
U following reason. (Section 7031.5. Holmes, and Pmfeaiuns Calc: Any city or county
m which rc4mrea a pennn m consmn, ober, Improve, demolish, fir repair any suucmre
prialas issilmoullwreyuirex the applicant for such permino file asignednmtnment
that he is licensed pursuant to the pn,wan.softhe Contractors License lrw (Chap¢r9
WCO0 (commencing will] Section 7000) of Divivina 3ofthe Business ural Pmfeswinns Cov)ur
e, L e C that he is exempt thcmfmm and he basis for the alleged exemption. Any vlolatinn of
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil Penalty of
t more than fisc hundred dolls,, (¢500).
SD I, as owner of the properly, or my employs, with wages as their sole compensmion.
L will do the work. and the structure is not intended oroRered for sale (Sm. 7015. Business
13 m and Pndesom, Colic: The Contractor's License Law Ates not apply to na owner of
propmy, who builds or improves thereon, and who aces such work hiosself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one year i feempletlon, the
owner -builder will have the burden of proving that he did not build or improve intent -
ase of vale,.
❑ 1. as owner of the property. am exclusively contracting with licensed conclumrs to
mAmel he Project (Sec 7014, Bnsiners and Pmfesoiom Calc:) The Conlmaurs Li-
osc Law does not apply to on owner ofpropcny who builds or improves thereon, and
who minmces for such pmjats witha crntracmr(s) licensed panuam to tae Commune,
License Law.
[-I 1 am exempt under Sec. , H & P C for this reason
QTY. ELECTRIC PERMIT I FEE -
Owner Date
WOR KI7R'S COMPENSATION DECLARA9'ION
I hereby affirm under penalty of perjury one of the following dcclamtions:
❑ I have and will maintain a Certificate of Consent to self-inautefor Workers Compen-
sminn, us provided lire by Section 3]0) of the Lahore Calc, far the perfoolumm of the
work for which this pennn is issued.
❑ I have and will maintain Worker's Compensation Insurance as required by Section
3701 of the Labor Code, for the performance of the work for which this permit is issued,
My Worker's Compensation la,m arm rerim and Policy mummer um:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSN'ION INSURANCE
This section need not Ise compinM if the pertrat is forma hundmddollars (S HKE
or less)
ccnify lhat int rfurmalar of We wort lin which his parotitis issued, Labatt
not employ soy Fetor ny meat so as pyye t Io the Worker, Compun-
z valor hes of Ca' o - . D to [�
z o Apphc:mt
.~N. NMICI3'rOA L a a Excmpunn, you should
a > become subject m the I nmpensation pmnzi ns of the La ryou mull
fenhwith comply wit such promsions fir this permit xhall he deaneal revoknl,
a�
z CONSTRUCTIONLENDING AGENCY
U
U Q (for haffirm that isaco (Sri.3nlending agency for the peHormancc of
It, work lbrwhlch this permit isinxucA (Sec 3(N)7, Civ. CJ
U Lender's Name
Lenders Address
Ir'I d I ccnify hal I read rM1h upplialinn and gale That the uhnve information is
N correct. 1 agree m « yswith all city oral aunty ortlinances and stem laws relathng m QTY.
U Y, buil ding am.amc' and hereby authorize represenmtives ofthis city to ether uptm tae
ohnvc cotta openy fere i u'rell oa Pureesc
(Wc g w save, indemnity and keep hurtnless the City of Cupeninn against
liahilitie. dg emsectDets.and eapcnuswhiibso/y� in any way seethe agaimt said City
AI'o [CAN' UWE �NUSIpMp W IDM: UMI'hVaWl'I'll ALL NON-POINt'
HAZARDOUS MATERIALS DISCLOSURE
Will 11hrr,li,int or future building omupant_garc or handle hazardous material
Inial by the Cupertino Municipal Code, Chapter 9 I and the Health and Safety
Section 25532(0)? /
❑Yes
Will the applle omr future (wilding occupant use equipment or devices which
hazardous is as defined by the Bay Area Air Quality Management
lily �
❑Yes m
me
T,
6 95 of the Cal,
nirand
alI-
sirand that if the
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02MAMPS
SIGNS ELECTRICAL L
SPECIAL CIRCUR/MISC.
TEMR METER OR POLE INS'I'.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES f
NEW RESIDENTIAL ELECTR SQ FI'.
PLUMBING PERMIT
PERMIT ISSUANCE f
AUTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -I INC.4OU'FLE S
GAS -EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WAS FEINTERcEri08
GREASETRAP
SEWER -SANITARY - STORM IIA. 300 FT
WATER HEATER WNF.NTNLECTR
WATER SYSTEM/1'REATING
WAI ER SERVICE
NEN' RESIDENTIAL PLMIL SQ. FT.
MECHANICAL PERMIT
PE.RMrr ISSUANCE J :.
ALTER OR ADD TO MECH,
AIR HANDLING UNIT T 10.000 CFM)
AIR HANDLING ONE (OVER 10.001 CIM)
EXHAUST HOOD(W/DUCT
HEAl1NG UNIT ('10 10000 B'IU)
HEATING UNIT (OVER 100.000 BTU)
VEND ILATION FAN (SINGLE BESIDE
BOILER - COMP (3HP OR 100.000 BTU)
BOILER - COME' (OVER Io0.0K)BTU)
AIR CONDE I'IONBR
NEW RESIDENTIAL MECH. SQ. Fr.
OFFICE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
I'rC11ENRFMODF,L
❑ADDITION
❑ PLUMBING RI PIPE
❑MULTrUNrr
El STRUCTURAL
MODIFICATION
ED INTERIOR
[I CHIMNEY RI7PAIR
IMPROV17NIENI'
(] SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL;
❑NEWBLDG/ADDITION ❑DEMOLITION
❑'I'FNANT ❑ FOOD SERVICE
IMPROVEMENT
A ❑OTHER
QF. OUR AREA Q.Pr
o � MAY 121999
FEE
E�Y
VALUATION
STOVES '1'YPECONSTRUCTION
OCC UP APN
g 3 V
BUILDING DIVISION FEES
PLANCHECK hili
ENERGYFEE
GRADING F1313
SOILS IEE
PAID
I fe Receipt p
TOTAL:
BUILDIN C bd
FEE SEES 4 Izo
FEL0& FEE O
PLIJ1,1{ 'G FE 17,
ME.0 NICAL FEE r in
CONS TR CTIONTAX
I HOUSING MITIGATION FEE I
PAID_
Date ReceiptN
ISSUANCE DATE