99080177_ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
(ITY OF CUPERTINOser rr r`ry BUILDING - L CFR
BUILDING DIVISION APPLICATIONIPERNIFF PLUMBING - MECRA:
ADDRESS.
665-0 Sze;_ x6TEy I ❑ Consultant Fees Paid by Applicant (Initial)
I hereby affirm that 1 am licensed under provisions of Chapter 9 (cnmmoncing
n�Z wilh Section 7000)of Division 3nflh,Businesxand Professions Code. and my license is
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g-UQF,- mfull
enseCccand eftpct.
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ARCHD'IfCI-S DECLARATION
P p y Z 1 unJerstunJ in, plam.Mull he uad as public record,
0Z �_n
I.iuusW Professional
OWNIam exempt
DECLARATION
�C Q 1 hereby affirm that 1 nm eumpt from the Contractors License Law for The
k 3 A. U follox'ing reason, (Section 7031.5. Business and Professions Code: Any city or county
X14 O NQ which requires a permit m conswct. alter. Improve, demolish, or repair any uructurc
SSnnJ prions as issaanee, also requimsrheapplicam nonsuch permit to Cie. signednmensent
Eby that her, Incensed parsmon It he ins ..... mnf me Commctor's Liacon,].aw(Chapter 9
+f 600 (commencing with Section 9000) of Division 3 of The Business and Professions Code) or
Y 6 a Ihu, he is exmmpT Therefrom and the basis for the alleged exemption. Any vielmiom of
ad oM 4 Section ]11315 by any applicant for a permit .subjects Ne applicant To a civil penalty of
� K m not muse than live hundred dollars (S500).
fXn O I, as owner nfthe propeny,orntyemployees will wage, axmeir sole compensminn.
F. will do the work, and thextracmre is not intended or offered for sale Cine. 704[41 Business
{Wu ce and Professions Code: The Convacon'x License Law does not apply to an , na of
prapeny who builds or impresses Thereon, and who does such work himself dr Through
his own employees, provided that such improvements an net intended or offered for
sale. If, however. The building or improvement is sold within one year ofeomplenum.the
ncobuilder will have the burden of proving that he did net build or improve for pur-
p..scot ulcJ.
C 1, as ev ner of the property, am exclusively contracting with licensed contractors h;
instruct the f just (Sec. VINJ, Business and Pon exsinns Coda:)The Contractor's Li -
cerise Law Jars not apply to an owner of propeny who builds or Impro as thro n 1. and QTY.
who contracts for such projects with a commctm(s) licensed punmam to the Commences
License Law.
D 1 am exempt ander See. . B & P C lar Ni, realm
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WORKERS COMPENSATION DECLARATION
I hereby off inn older Iwnahy of perjury one of Ne following dedunallons:
I have and will maintain a Ccnificale of Consent to self -insure for Worker's Compete.
v, provided for by Section 3700 of the Lubar (ode, for the performance of the
Irk for which This permit is issued.
'TjJ`I have and will rommaire Worker's Cnmpenst ion Insurance, as required by Section
OO of the labor Code. lot the performance of the work for which this permit lx issued.
My Worker's Compenruom mmneeca JPolieyy�,ler-9R appy
Cuuirr. — me Policy Nn:
S
LERTIII ATIi OF IiXbdopll0N FROM WORKERS'
COMPENSATION INSURANCE
((Tis echmn need oat IveconlpletW if Ihepennit ix Ibnmc M1undreJ dollxrs 1811X1)
or less.)
I eroh That in Nr perfurmmrcrnldo, work for which this permit is issued, Ishall
not employ any person in any manner so as in become subi b the WorkersCount
7-s clion Lens—I Califnmla. Ore.
ZO Applicata
tiNOTICE TO APPLICANT: If, after making this CeniEcate of Exemption, you should
become xubjccuo IM1c Worker's Ce.n;penemion provisions of The labor Code, yon must
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forthwith comply with such provisions or this permit shall be deanW revoked.
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CONSTRUCTION LENDING AGENCY
VQ (hereby affirm that isaconswction lending agency for the performance of
LL P The work tar which this permh is „sued (Sec 3097. CivC.)
0 U Isnder's.S'ame
Linder', Address
y I certify that 1 have reu1 this application and state that The above information is
Z) correct. 1 agrre m comply with all city and county ordinances and sate laws relating to QTY.
LIZ building emnionctioq:md hereby nommrim reprewmetwe,.1 this lily m corer upon The
abrvcmetaioned property for inspection putpoas.
(We) agree to Tuve, Indemnity and keep too o leis Thu City of CupcNno against
liabilities, judgments, costs and expenses which may in any way accrue against said City
In ronxegalme of the granting A his Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
e ITAPARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupam store or handle norank es material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the HadN ;,old Safety
Code, Section 255321x)"
EZYcs E] No
Will The applicant or future building occupant use equipment or devices which
. vJous air eundoomard, as defined by the Hay Ared Air Qoaliy Management
d'
Ir]Ycs [-I No
I have read the hamrdnus Taerlalx rcyuiremen.x under Chapter 6.95 of the Cali -
Extent Health at Safety Code. Sections 25505, 25533 and 25534. 1 understand Nal if the
building does not cunenfly�we a tenata,jt�jkf"my responsibility no notify the occupant
S
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP'10200AMPS
TIiMP MITER OR POLE INST.
POWER DEVICES Bill' DINC
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ ET.
PERMIT
FERMI "1' ISSIJAEEC s
ACrER- DRAIN&Vii -WA R( )
BACK FLOW I'ROTIiCT. DE
DRAINS - FLOOR, ROORA .0 U.
FIXTURES - PER TRAP
GAS - F.A. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRE, WASTE INTERCEPTOR
GREASETRAP
SIMER-SANFTARY-S"TORM EA. 200 FT.
WATER HEATER W/VENTTLECFR
WATER SYM:MITFEATING
WATER SERVICE
NEW RESIDES I'[A]. PLMIL SQ. I'T.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR IIA N DUNG UNIT fID FoLodd CFM)
AIR HANDLING UNIT OVER 10.000 CFM)
EXH A UST HOOD(W/DUCT)
HEATING UNIT (TO 100,0110 BTU)
HEATING USE r (OVER IIp.00) it'1'U)
VEN'1'1 LAT ION FAN ISI NO LP, RESIDE
BOILER - COMP (31 IT OR 100,000 R'I'U)
HOILER- COMP (OVER IBLOW BTU)
AIR CONDITIONER
NEW RFSIDENTIALMECH. SQ. FL
OFFICE
TOTAL'.
qPGL 1 NO.9� 1' t
NI'1'ARY NO. APPLICAT A
NIC COM ROI.
El
BUILDING PERMIT INFO
BLDG ELECT' PLUMB SHIELDr; I—Ii it]
J013 DESCRIP LION
RESIDENTIAL:
D SFDWL
D KITCHEN REMODEL
DADDITION
C PLUMBING RE -PIPE
❑MULTI-l1NIT
CSTRUCTCRAL
MODIFICATION
C INTERIOR
[ICHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
C BATH REMODEL EPAIR
C1 DEMOLITION
D OTHER
COMMERCIAL,
CNEW BLDG/ADDITION
[-]DEMOLITION
CTCNANT
[I FOOD SERVICE
IMPROVEMENT
COFFEE
SQ. FT. FLOOR AREA b/SQ. FT.
FEE
VALUATION
O 6PE
STORIES ' I'YPE' CONDUCT ION
OCC. GROUP 4/2—APNZ/
117 1
BE DING DIVISION FEES
PLANCIALCK FA 7 357
ENERGY FE
GRADING FEE
SOILS FEE t (�
1r � 1 ale Ric �I M 11 1
'1 v TOTAL: 11111
BUILDING E o Flj U
FEE SEISMIC" 1
EI.ECfRI FEE�i�
PLUMBIN ``II�4
MECHANICALFEE
CONSTRUCTION TA
HOUSING MITIGATED FEE
PAID
Date ccxipTx
'T(yrAL: 077
ISSUANCE DATE
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