S 0499APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
clTv Or curr:RTINo BUI I.DING - ELECIRACA I. PFRMI'P dao .
BUILDING DIVISION APPLICATIONITERMIT ul n PLU511tING-MECHANICAL. S 0 4 9 9
N.1' nenu:rTmBVTWICATION
❑ Consultant Foes Paid by
MWZ
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 9000)ofDi,i,ion 3oflhe Bestow, and Pndest ...I, Code, and my license is
I„�O Inftllfnm an Ifal. .
�UU Li, oro all hieN
F Z IX¢ Comrdc or
ARCHITECT'S DECL DON
Z ^ Z 1 understand my plane shall he used as puhl mdx
4 Licensed Profc„ianal
sid OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from The Contractor's License Lnw for Lha
aU following reason. (Section 7031.5, Business and Prdes,iom Code: Any city or county
LLea. � which require, a permit on emooduct, alley, improve, demolish, or repair any xbralme,
prone its issuance, also requires the applicant for mel permit,, file a signed statement
That he is licensed ismendt to the provisions of the Contractors License Law (Chapter 9
oy, C, (Commencing with Section 9000) oisi
f Di, 3oOha Business and Profe,sions Cade)or
but he i -s exempt haea mm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any appllcam for a Permit object, the applican in a civil Family of
Z y not more than five hundred dollar, ($500).
E=C I] Lo nwner of tie proscny, ntendd or offered fergir far .[a
rSole compsmmis,,
will dothework, andthehstructure Concis act intended Lawdoforole(Sec.o an Business
u�l ~ and property
what
Cade: The oyes marina Licence Law fires not apply m an owner of
TY 3 propeny who build, or improve, Thereon, and who nts are n work intended
or or through
his own owesercea. provided r n psuchroc imams sold w thin not intended or nittrcd foe
miel6dilmor iThebuildingant Intprovcment is hwithinaneyearof prove tforpr,
on, the
weer-M1uilJer will have the harden nl proving that he did an build or improve for pur-
pose of role.).
0 I, as owner of the propeny, am exclusively connecting with licensed con[ract,,r to
construct the project (Sec. ]BW, Business and Professions Code:) The Comractors Li
cense Use does not apply to an owner of propeny who builds or improves thereon and QTY.
who contracts lin Such projects with a evmloscou s) licensed pursuant o the Conorecmra
Liamw Law,
0 1 um exempl under See. . H& P C f n This reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty,d perjury one of the following declarations:
I have anA will maintain. Ceniticmc of Consenuo wlDinsure for Worker, Courpen-
Nium, as provided for by Seclinn YIN) of the Labor Coda, for the Performance ol'the
work for which this permit in issued.
0 I have and will maintain Worker's Com eadc l on Insurance, as required by Section
37M of rhe Inbar Code, for the performance of the week for which this permit is issued.
Wnr'r Cnnpcnsation a c rie ando
Caca Policyy NNa::
CEPUT FI CO OP SATIONII N FROM WORKERS'
COMPENSATION INSURANCE
fl'hlx ar<linn need nom he ummpletel ifthe permit is l'drone hundred dollnrx ($I lN))
let's.)
I cenify that in the perfun adce of the work for which [his permit is issued, l shall
mol employ any pecan in any manner so as m become subject to the Workers' Coripen-
z moon Law,nf California. Date
O Applicant
F7 NOTICE TO APPLICANT: IL alter making this Coni from of Exemption, you should
a back)=,Lhjml to [la Worker's Compensation provisions of the Labor Code, you mus,
W.forthwith comply willsuch IF visinnsor this permit shall M med re
deevoked.
7 z CONSTRUCTION LENDING AGENCY
L) O I hereby affirm that hem is a construction lending agency for performance of
D. F the work for which his perch I. issued (Sec. 301 Co. C.)
0 Lender's Name
Lender's Address -
1 certify That I have read IOL, application and state thin the above nomination Is
o-FrN contact. l agree m comply with all city and county oniri and state laws relating am QTY.
V Z building construction, and hereby amhmize representatives of this city[. ene,.,.,he
above-mentioned property for inspection pdryose,.
(We) agree to save, indemnify and keep handless the City of Cupertino against
linbihJgment5,cat, and expenses which may in any way become against said City
in car, a nt the gQQ}}''ming of This permit.
APP(T�NDERFTANDS AND WILL COMPLY WITH AL1, NON -POINT
SOU.OULATI/.CNS. /
'$ignlluy(f AppliciR/i ConGifu Hale
11/Ir/,r9,('/ HAZARHO ATERIALS DISCLOSURE
I The applicant or lunar It
ding occupant score or handle ha,ardoe. material
ns de Oil Lha Cnpe lino Mu
al Code Chnpmr 9.12, and the Ile Ilh ;I I Safety
Code Se lion 2.55330)1
OVc, ON.
Will the applicant or future building occupant use equipment or device, which
emit hazardous air contaminants as derided by the Buy Area Air Quality Management
Dismay
❑Yee 0 N
I have mad rhe huvaremm oa[eriols rerimmucnn under Chapter 6,95 of the Cali-
fornia Health & Safety Cade. Section, 25505, 25533 and 25534.1 undeoand Thal if the
building docs not currently have a tenant. [hat it is my resrym,ibility to notify the reactant
of the re,m acmes which most be me[ printed Tmuanm of a Caormone of 1Rcepancy.
ELECTRIC PERMIT FEE
PI in III I ISSUANCii
A PPLI ANCES — RESIDENTIAL
PANELS
UPTO 2M AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUITAMISC.
TIEMI'. METEROR POLE (NST. A
('OWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RESIDP,NTIAI, ELECfR SQ Pf.
160
0
BUILDING 1117RMIT INFO
BI.DG ELECT
PLUMB MliCll
❑ ;R
❑ ❑
JOB DESCRIPTION
TTY Ur LUrEfiIINU
RESIDENTIAL
DRAINS— FLOOR, ROOF AREA, COND.
❑SFUWI,
I] KITCHEN RHM(IDEI,
❑ADDI'T'ION
0 PLUMBING RI}I'IPE
EIMUC11-UNIT
❑STRUCTURAL.
BUILDING NVISION FEES
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOIS
0 HATH REMOD I'0
U I.11'ION
❑ oUGE t
WATER SERVICE
PAID ,_ _..... .
NEW RESIDENTIAL PLICUL SQ. FT
COMMERCIAL,
❑ NEW BI.DGIADDITION
❑DEMOLITION
0*117NAN'f
❑ FOOD SERVICE
IMPROVEMENT
0 OTHER
a -r. -D
I PAID
SEP 16 REc
SEISMIC (IEE
PLUMBING PERMIT FEE
FIRM]] ISSUANCE
DRAIN WATER (IEA)
TTY Ur LUrEfiIINU
OWPR&VENT—
SACK FLOW PR01'F:CI', DEVICfi
BACK—
DRAINS— FLOOR, ROOF AREA, COND.
SFORIES
(ICC. GROUP
TYPE Cf
FIXTURES—PER Fit Al'
GAS —EA. SYSTEM -I INC. 4 OUTLET'S
GAS— EA. SYSTEM OVI7R 4 (EA)
GREASHINDUSTRI. WASTE INTERCEPTOR
BUILDING NVISION FEES
GREASETRAP
PLANCHECKFP.E
SEWER — SANITARY —SFORM EA. 200 FT.
ENERGY FEE
WATER HEATER WAVENTAELECTR
GRADING ItiG
WAI PIT SYSTEMO'BIEATING
SOILS FEE
WATER SERVICE
PAID ,_ _..... .
NEW RESIDENTIAL PLICUL SQ. FT
MECHANICAL PERMIT FEE
BUILDING F t.
SEISMIC (IEE
PERMIT ISSUANCE
ELECTRIC PGE
AUI'ER OR ADD TO MECR
PLUMBING FEE
AIR HANDLING UNI 'I(TO lCFM)
MECHANICAL FI3
AIR HANDLING ONI'i'(OVF.R 10.00D CFM)
CONSTRUCFIO TAX
EXHAUST HOOD (WADUC)
HOUSING MITI TION FEE
I IEAfING ON[ 1 00 100,IXp BTU)
HEATING UNIT (OVER I 0i BTU)
VENfIf TION FAN(SINGLEFAN(SINGLE, ROSID)�PAID
Doc R. rip[p
BOILER— COMP (3HP OR 100.00❑ BTU)
TOTAL:
BOIL — COM('((VIER 100jil 1 B' 1' U)COM('((VIER 100jil IB' 1' U)
AIR CONDI 'I'IONGR
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
$ASQ. FI'.