28629APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION
)ILDINGADDRCSS:
/11///0
VNLR'S p; NAME:
tC CT /ENGINEER:
INTACT:
petdiv l,,,
APPLICATIONWERMIT
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t/ 1.. %ni III
-O� I ❑ Consulterit Fees Paid by Applicant (Initial)
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing -
with Section ]OW) of Division 3 of rho fiosinesx and Prnfossinns Crrdc. and my license is
in fall farce and effect.
License Clues Lic.0
Dam Commcmr
ARCHITECTS DECLARATION
1 understand my plans shall he used i s public records
Licensed Professional
OWNER - BUILDER DECLARATION
1 hereby affirm that 1 am exempt Baratta, Cmaric ors License Law for the
following remon. (Section 7031.5, Business and PnffeWons Code', Any city or county
which reryince a perm, ui consimm, alter, 'nnpoem. dental kh, or repair any smuure
prior m its issuance, elm requires the applicant far sucM1 pmank a, flea signed statement
that he is licensed pursuant to the provisions of fire Contractor's License Low (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cods) or
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any npplicent for a permit .mem s the applicant to a civil penalty of
not more (ban five hundred dollars (5500),
C] 1, as owner of the property, or my employees with wages as their sole compensation,
will dote work, and the xtmeme, is not intended or offered for sale (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or famish
his own anployess, provided that such inmprovements xre not amended or offered for
see. IL however, the building or improvement is sold within one year of completion, the
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ has owner of the property, am exclusively contracting with licensed contmmors to
construct the mucc9 (Sm. 7044, Business and Professions Code:) The Cont to
racr's Li
tense Law does not apply nr an owner of property who builds or improves thereon, and QTy.
who contracts for such projects with u enmmemr(s) licensed pursuanno the Contract.
License Law.
❑ I an exempt under Sec. .B &PCT t
Owner Data
s WORKER'S COMPENSATION DECLARATION V
I hereby affirm under penally of perjury one of the following declaration:
❑ I baveand will maimaina CorralmteofConseamae16insure far Worke10'Comp
stated, as provided for by Section 37M of the Labor Cade, far the peH 1of en.
work for which this permit is issued.
❑ 1 have and will maintnin Worker's Compensadoo Inmoram. as rcyulrcd by wi
Sumo e farm, C90, for the pnEmom. of the work for which this ps,,At is issued.
M ark C nlnaurance ca normal Policy numberere:
Tr Policy No.:
(PICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need net be completed if the pemm0 is for one hundred dollars G1 WE
or less)
I comfy that in the performance ofthe work for which this permit is issued, l shall
sot employ any person in any ra m
n n ter as to become subject to the Workers' re
Compe
0 Z sation Laws of California. Date
Z 0 Applicant _
y NOTICE TO APPLICANT: IL after making this Cenifmcum of Exemption, you should
a ; become subject to the Workers Compensation provisions of the Labor Carlo, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY,
U 0 (hereby affirm that there is o cnnsamerion lending agency for the performance of
U. f" the work for which This permit is issued (Sec. 3097, Cis. C.)
0 V Lender's Name
(1.1 Lender's Address -
i1r i cenily That 1 have read this upplicatimm aW runt that the above infaramtion is
sr y coned. I agree to comply with all city and county ordinances and state laws relating to QTY,
U s� building coustmction. and hereby manicure representatives of this city to emer upon the
above - mentioned propcny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupci ins, against
liabilities, judgments, costs and expert which may in any way creme against said City
in wnsequcnce al the rzanting of this spermit.
APPLICANT UNDF 'STANDS AND WILL COMPLY WITH ALL NO POINT
SOURCH REG Ord
5 /1 f 9 t_
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building recupam store handle lamardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code. Section 25532(x)1
❑Yes No
,Ira haWill the applicant or future building occupant use equiPmem or devices which
raa dous air contaminants as defined by the Bay Area Air Quality Management
District^
❑Yes E] No
I have read the micamus materials mquiremems under Chapter 6.95 of the Cali.
forma Health & Safety Code. Sections 45505, 25533 and 25534.1 understand that if the
building does not currently have a tenant, that it is my resPnribility to notify the monsoon
of the requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or mthodzed agent - Data
SANITARY [
I NIC
ELECTRIC PERMIT FEE
PERMIT' ISSUANCI?
APPLIANCES — RESIDENTIAL
PANELS
UPI'02(KAMPS
SIGNS ELECTRICAI.
SPECIAL CIRCUI'VMISC.
TEMP. METER OR POLE INST.
POWER DEVICES t`
SWIMMING POOL ELECTRIC`•;
OUTLfi fS — S W ITCHES — FIXTURES
NEW RESIDENTIAL ELECTR SOFT
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER — DRAIN & VENT— WATER DfA)
BACK MOW PRUE ECT. DEVICE
—PA. SYSTEM-] INC.4 OUfLE'1'S
— /9 "�M-OVER 4(EA)
4S Ws ORL WASTE INTERCEPTOR
GREASETRAP
SEWER —SANITARY —STORM EA. 20017T.
N'A'GIR HEATER WNHNT/ELECTR
WATER SYS ILMO REATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. rL
MECHANICALPERMIT
PERMIT ISSUANCE!
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.00) CFM)
AIR HANDLING UNIT (OVER 10.000 CUM)
EXIIAUSI' HOOD DVID 3CT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENT ELATION FAN (SINGLE RESIDE
BOILER — COMP (3HP OR 100,000 BTU)
BOILER — COMP (OVER 100,00 BTU)
AIR CONDITIONER
NEW RHSIDENTIAL MECH. SQ. FT.
OFFICE
FEE
FETE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ DDITION
❑PLUMBING RE -PIPE
LTI-UNIT
❑STRUCTURAL.
//
MODIFICATION
El INTERIOR
11 CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REh fP/
Di -NLUI A�
THIi
' Dam
eceiptN
49M,
I ;
COMMERCIAL
❑NF.WBLDG /ADDITION
❑DIEMOLITION
❑TENANT
0 17001) SERVICE
IMPROVEMENT
❑ OTHER
aL.
STORIES TYPE CONSTRUCTION
•sMAR 121996
CI IY Ur VUf- I
BUILDING DIVISION Flit APN
PLANCHECK FEE
T 1
i
ENERGY FEE.
'GRADING I7CE
SOILS FEE
PAID
' Dam
eceiptN
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HOUSING MI'TIGATH N FEE `
PAID
' Data Receipt M
O
ISSUANCE DATE „
ISSUED B :
AS-
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