99110158APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINTOPEN ON
Talent
RESIDENTIAL:
I S yS
rTi
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
ING
PLUMBING = MECHANICAL.
_ ,,
BUILDING PROJECT IDENTIFICATION
❑ PLUMBING RE -PIPE
S'0001
P�n o��
BUILDING AUURF.$S:
' MODIFICATION
EJ INTERIOR
SANITARY
NO.
APPLICATION. ALDATE
❑ BATH REMODEUREPAIR
❑ DEMOIJ TION
❑ OTHER
Dam Recai'a#
OWNER'S AME'. CF n�M H P E:� --�� .63
CO TR ACTOR'
BUILDINGFEE
NIC
❑
SEISMIC PEE
C TROLH
o S
ARCHIIEC/F, GINEER: LI CN :
c a-; . z
ADDRES :
sir I. 9,
CONTACT: - PHONE: - �'
11 %� ,5/a/�
1 GL1�CQ', CA651 C i �J7
-
El Consultant Fees Paid by Applicant(Initial)
MECHANICAL FEE -
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
❑ ❑
LICENSED CONTRACm DECLARATION
WZ
1 hereby off nnoun 1 licensed d p of Ch to 9'( tame 'ng
with SeUlmn7funsoafOipetite Burls. OP f,su.Cad d bee n
ly in full force and efieet ^.f �
�UF License Cles L'ek
Ha Dene
ARCHITECTS DEU ATIOIV
F' h Z 1 underemntl mY plans snail rte need as pnMic records
'oz=o
F S3t�i Licensed Professional
OWNER -BUILDER DECLARATION
I hereby .(Peen that 1 am exempt from the ConhaetdC,Corr L: Ad, c ty for the
0.i U following reams.. panel , 9onstr Business and Professions Code: Any city ormolu.
which renuirea a permit m construct, alto, improve, demolish, file
repair any tWment
'hat he incensed eaBort to the the provisions ofcaut for Connermi'mfileae Law Comment
t'1yC� thathoislie,wit pursuant to the provisions of the eBusinessa License Law(Chapter
a
..00 (ethers ingwiNhedfromon an the of basison
oeslippeiuesanspar An mis C. Insufma r
W q o y
that he is exempt therefrom and the avers for the subjects
th d applicant
to Any l penally o
I {+�. Section 7031.5 by any applicant for a permit subjects the applicem to n civil penal. o
not more than five hundred dollars ($50T.
❑ do the
properly,rmyemplendes orNwred for ack,(See. compeneours
willdo Shawork, andtheocmmistors License
raw dotarsalepply to
Beninese
11 we and-fi'nlessions Coda: The Contractors License Low does not apply m an owner o
propedy who builds or Improves thereon, and who does such work himself or througl
las own employees, provided that such Improvements am not intended or offered fo
sale. If, however, the building or improvement is sold within one year of completion, the
owner,builder will have the burden of proving that Im did not build or improve for pur-
pose of sale).
❑ 1, vs owner of the property, am exclusively connecting with licensed contractor to
onswct the project (Sec. 7094, Business and Professions Code) The Contractor'x Li-
mnsm Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such pogim¢ with a continuous) licenced pursuant o the Contractor s
License Law.
❑ lamexentpOr Sec . .B&PCm hishae
p f tn. 2 _
_ '\ I. <( MPF.NSATIONDECLARAI'ION
I hereby strum under petmlty leperjuryencofthefollowing orkeriCo
I have and will for by Se tion Scam of Consent mCodencure for Workers of es -
the
cation, as provided for n Section 3900 of the Labor Cade, for the performance o[ the
work for which this permit is issued.
❑ I haveof
will maintode,f r s, performance
Compensation work
bins requiredby Section
Myan the Labor Code, fenheperfonna aro Of thewary fnumberh his permit is issued.
My Wnrk is Com tion li��IL y7^'er and Policy number are-
Cam
re' /y
` Carzieer j.�- K Policy Na: �IJr
CERTIFICATE OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(This oultim need mol be completed ifthe permit is forcouleadmd dation ($100)
or less)
Icenify thenin theperfnrmanceof thcworkfor which this permit is issued, Ishall
net employ any person in any manner so as rot become subject to Ne Workers' Grmperr
'Z. cation Laws.1 California. Date -
O O Applicant _ _
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should
abecome subject to the Workers Compensation provisions of Ne Labor Code, you must
Wronhwith comply with such provisions or this permit shall be deemed revokel.
Q
(1❑t CONSTRUCTION LENDING AGENCY
U Ihereby affirm that them is a construction lending agency for the performance of
W Fthe work for which this permit is Issued (See 3097. Civ. C.)
O Udander's Name
Lenders A land,
a I cavity that 1 have read this application and sate that the above information is
F., h correct. I agree to comply with all city and county ordinances and state laws relating to
:.1 huitding construction, and hereby authorize representatives of this city to enter upon the
above-memieued prnpeny for iuspeaion purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
hi bili es,judgmenu, monis sed expenses which may In any way accmesgca st avid City
-in cano'c'uncre of the granting of th'r(Fn t.
APPLICANT CHOW STAN, S N ILL COMPLY WITH AIA N -POI T
SOURCB RE N: Q
Signature 15f APPllcanuCamrecmr Dart f
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant r future building occupant store er ho rdle moundons material
as defined by the Crinoline Municipal Code, Chapter 9.12, and Ne []curb and Safely
Cede, Section 25532(a)I
❑ Yes
Will the upplicnotfuture building occupant use enuipment or devices which
mit hazardous air me corinams as defined by the Buy Area Air Quality Management
Dtsdm9
❑Yes
I have read the hazardous mutaitds reyuire arm, under Chapter 6.95 of the CGIi-
fomin Health & Safety Code, po 5505 5533 and 25534. 1 understand that if the
m
builiingdoc, urr7at0ytr at m, th, n is my msperaibill.lyorify the train
ter rhe+euwr wild .uctoo ro lnauence ofa Certili to of Oce v.
. rELECTRICPERMIT FEE
PERMIT ISSUANCE ,
APPLIANCES -RESIDENTIAL
PANUS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCULUMISC.
QTY. PLUMBI BRMIT' F,BE --.
ALTER- DRAIN & VEN Fc%kvAA.K Bro
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR, ROOF, AREA, CON
FIXTURES - PER TItAP
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS -EA. SYSTEM -OVER 4 (EA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEMepREATING
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
PERMIT ISSUANCE
ALTER ORADDTO MECH. '
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT(OVER 10,000 CPM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT' (OVER I ported BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,001) BTU)
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. FT.
OFFI
JOB DESCRIPTION
RESIDENTIAL:
❑ SPDWL
❑ KITCHEN REMODEL
❑ ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
❑STRUCTURAL
PLANCHECKFEE
' MODIFICATION
EJ INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑ DEMOIJ TION
❑ OTHER
COMMERCIAL,
WNEW BLDG/ADDITION El DEMOLITION
fENANT ❑ FOOD SERVICE
SQ, FT. FLOOR AREA
ISSUANCE DATE e
ISSUED BY:
OCC. GROUP
"BuiLDINOUIVf31
PLANCHECKFEE
ENEIIGYFEE
GRADING FEE
SOILS FEE --
PAID
Dam Recai'a#
TOTAL
BUILDINGFEE
FEE /
SEISMIC PEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE -
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dom Receipt
ISSUANCE DATE e
ISSUED BY: