31468APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY'
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CITY OF CUPFERTINO ' , I BUILDING - ELECTRICAL
BUILDING DIVISION' APPLICATIONIPERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
PERMIT NO 1�.i q /�/1
Jill 4l6J l8J
PERMIT ISSUANCE
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BUILDINGAIIDRESS: -
o2lD� ila OriYe ha �/
SANITARY NO..
APPLICATION AL DAFT
2
�C.'S NUMB: PHONE
//ENGINEER:
C RAC OJ2" AM LIC NO
N/C
❑
CONTROLa ,
AC•RRCCHHII{TEECf LICNO:
A ) : gz
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CONTACT: PHONE.
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❑ Consultant Fees Paid by Applicant(Initiap
BUILDING PERMIT INFO
BLDG ELECT ME MECH
❑ ❑ ❑
I EMT. ME' I ER OR POLE INST.
I hereby aRfirm that 1 an licensed under provisions of Chapter 9 (commencing
QZZ with Section RXIBIof Divisba3afd¢ BuslnessaTW Pmfeaa1aZxCWg2d my licenseis
I- W r In full farce 9nd eITe
U U License Clas Lie N,
HGL Date— �Cortmctor
ARCHITECTS DECLARATIO
n C Z Z 1 understnd my plans shall he used as public rtrn
� lQ Z { Licensed Pmfeaucand
a-] OWNER - BUILDER DECLARATION
I hereby affimt that 1 am exempt Trott the Contractor's License Law for the
0,U fal lowing rcasoa (Section 7031.5. Business and Professions Cede: Any city or c umy
ON which requires a permit m consumer, alter improve, dentoRN, or repair any swan«
prior to its iAmnice, nlsa «gams the applicant for such permit to file a signed statement'
that he is licensed pursuant to the provisions of the Contwtor'x License Law (Chapter 9
aCC (commencing with Section ]000)of Division 3 ofthe Business and Professions Code) or
ti o C that be is exempt thertmm and the basis for the alleged exemption. Any violation of
m Section ](131.5 by any applicant for a permit subjects the applicant m a civil penalty of
F Z Y not more rhnn five Inlndru] dollars (ESgB.
'F G CI, as owner ofhe pmpeny, or my employees with wages as their sole compensation,
will do No work, and the smaetwe is not intended oroHared for sole (Sec. 9044. Business
_ end Praficamw Code : The Camtranors License Law does our apply to un owner of
JG property who builds or improves thereon. and who does such work himself., through
his own employees, provided that such improvements ase rat intended or offered for
sale. If, however. the building or improvement is sold within one yearofcompiction, Ne,
owner- huilder will have the burden of proving that he did not build m improve for pur -'
pose idmitJ. ' "I I
1, as owner of the property, am exclusively contracting with licensed conhumors to
construct the project (Sm. ]BW, Business and Professions Code:) The Commmoe, Li.
cerise Law does not apply to an owner of property, who builds or improves thereon, and QTY,
who contracts for such pmjeers with a commemr(s) licensed pursuant to me Conimemrs
Llccroso I'm, I -
❑ 1 am exempt under Sec: B & P C for this reason
Owner Date `
WORKER'S COMI'I.NSA'I'ION DECLARATION
/i I hereby affirm under penalty of perjury one of me following dZxIZmaiom:
0'1 have and will maintain eaten acme of ,hc Lab., Craft, tfop Worker's Compen-
sation, ,provided for by Seaton J]qt of thu Labor pule, Car Nc performance of the
work for which this permit is issued. •'
I have and will maintain Workers Compensation Insurance, as required by Section
3] ) of the labor Code, for the perfamranccaf Ne work for which this permit is issued,
My Worker's p �9Y99�; ce artier and Policy n ��¢;. ��7 /��
Orrriv: r.4S'
CERTIFIC COMPENSATION INN FROM WORK iRS'
COMPENSATION INSURANCIi
(91ix am0on need not hecomplded ifthc pemtit is for ono hundrrA dollnry IE110)
• ar less.)
l certify that in the in any m n manner an the work for which this permit is a s' Co I per -
m[t enlLaw of person in any manner an m m become subject the Winters' Cnmpen-
,� Arioa Laws of Califnmia. Darr Z. O Applicant
tq NOTICE TO APPLICANT If, after making Nis Provisions of �xemption, you soon ld
F become subject m the Worker's Compensation provisions of The loiter Code, you most
foMwith comply with such provisions rn this •permit shall be deemed revoked,
Uj z CONSTRUCTION LENDING AGHNCY -
I hereby affirm That there is a con.amction lending agency for the performance of
U 0 ;I a work for which this permit is issued (Sm. 3097, Civ. C.)
U Lender's Name
fJI Lender's Address
y I certify that I have read this .,],can.. and auction me above informntiom is
N correct. I agree m comply with all city and county ordinances and state laws refining to QTY.
U building mnariNfion,end hereby autharim« prcsenmtive9 of this city to emerupan the
above- mentinnW property for inspection purposes.
(We) agree to save, indemnify and harm
keep halexs the City of Cupertino agaim.0
Iubiliries,judgments, coin and expenses which may in any way accrue apimt said City
in tannmarra, of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. -
v Signature of AEa imrdsC.nhxrmr - Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupem store mf ondle hoeuvitms material
as defined by the Cupertino Municipal CWe, Chapter 9.12, and the Health and Safety,
Code. Section 25532w)] '
s ❑Yes No
Will the applicant m forum building occupant use rymlount or Aevices which
mar hazardous air contaminants as defined by Ne Hay Area Air Quality Management
Di... Za? t
❑Yes El No
I have real the hazaalm e, materials reauman,,tas aroW Chapter 6.95 f the Culi-
iumia Health & Safety Code. Seatme, 25505 25533 and 25534 1 undeZ,1and that f the
6 ldir�BWp+Jj««s not currently have a repayy Nm't' y p 'billy. i ffy the x opera
opNG atremcnks which must be R .1dWo, hAunm of a Ccri EcrosrsC Occrms0ras&
ELECTRIC PERMIT
I FEE
JOB DESCRIPTION
RESIDENTIAL:
CSFUWL ' C KITCHEN REMODEL.
CADDITION El PLUMBING RE -PIPE
CMULTFUNIT - CSTRUCTURAL' '-
MODIFICATION
❑ INTERIOR C CHIMNEY REPAIR
IMPROVEMENT
C BATH REMODEIJREPAIR El DEMOLITION
' ED OTHER
PERMIT ISSUANCE
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-
APPLLWCES - RESIDENTIAL
PANELS
UPl "02W AMPS
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201- 100DAMPS
OVER IBg1AMPS
'"
SIGNS ELECTRICAL
SPECIAL CIRCUIT /MISC.
I EMT. ME' I ER OR POLE INST.
COMMERCIAL: -
CNEWBLDG /ADDITION, [:]DEMOLITION
❑TENANT CFOODSERVICH
IMPROVEMENT
CDFHER
POWER DEVICES
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SWIMMING POOCELECfRIC,
OUTLETS- SWITCf1E5- PIX'fURFS
NEW RESIDENTIAL ELECTR SQ IT.
-
SM LV0RNRP
' W
,Y L/r ��r[T11JJVU
WSQ. FT
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TOTAL:
PLUMBING PERMIT
FEE
PERMIT ISSUANCE
ALTER -DRAIN & VI ?NT- WATER (ILA)
VALUATION �s
- J
i
BACK FLOW PROTECT. DEVICE
DRAINS - FI,OOR, ROOP, AREA, COND.
STORIES.
TYPECONS'FRUCTION
"
PIXTURM - PER TRAP
GAS- EA.SYSTEM -I INC.40UTLE1'S -
Dec. GROUP
APN
GAS -EA. SYSTEM-OVER 4 (EA)
GREASFIINDUS'FRL WASTE INTERCEPTOR
BUILDING DIVISION IFIS
GREASETRAP
-
-
PIANCHECK FPE',
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SEWER - SANITARY -STORM RA. BE FT.
ENERGY FEE
,
WATER HHAI ER W /VENT/ELECTR
GRAVING FEE
WATER SYSTHM/IREATING
SOILS FEE
WAI 17R SERVICE
PAID'
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NEW RESIDENTIAL PLMB. SQ. FT.
Date- Receirna
TOTAL:
TOTAL:
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BUILDING FEE
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MECHANICAL PERMIT
FF.E
SEISMIC FF.E
PERMIT ISSUANCE -
ELECTRIC PEE -
ALTERORADDTOMECH.
PLUMBING FEH
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE all
AIR HANDLING UNIT (OVER 10,050 CFM)'
CONSTRUCTION'TAX' a
EXHAUST HOOD (W /DUCI) HOUSING MITIGATION FEE
HEATING UNIT (TO 1(1(1,(1011 BTU)
HEATING UNIT (OVER 100,(100 BTU) • -
VENTILATION PAN (SINGLE. RESID) PAID
Date Receipt#
BOILER -COMP OHP OR 100,000 BTIp
- "TOTAL:
BOILER -COMP (OVER 100k0DEl BTU)
AIRCONDITIONF.R '' ISSUANCE DATE
NEW RESIDENTIAL MECH. SQrF`L -
ISSUED BY:
OFFICE '