S 1923APPLICAN FTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLV
CITY OF CUPERTINO BUILDING ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDEN'TIF'ICATION
PE IT NO.
1923
BUILDING ADDRESS:
�'�-L
SANITARY NO.
APPLICATION SUBMITTAL. DATE
7
OWNERS NAME: PHONE'.
'
CONTRAC NAME: H/. LIC NO'
L +� GG� / /16 U s _ -�
N/C
CONTROLM
ARCHITECT/ENGINEER: LIC NO:
ADURE
��s
CONTACT: PHONE:
3 C 5— // / 1� r
J O
Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
❑ 11 El
LICENSED CO RAC! S DECLARATION
1 hereby aft mal I am heenxed made pm.iamna nr chapter 9 mummenciag
withSection tome ndl9fa DlvismnnJ of the Bnaint./esn vnd Professions Cada, and my license is
Lionise Cla snd�(ex��LiaF� 7�
4 Dam Con
QTY ELECTRIC PERMIT FEB'
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL LJ KITCHEN REMODEL
❑ADDITION [I PLUMBING REPIPE
Ll MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
El INTERIOR (�•CF((MNEY REPAIR
IMPROVEMENT POOLS
El BATH REMODEUREPAIR El DEMOLITION
❑ OTHER
R
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECTS DECLARATION
L J�ndrrpuna at pmnx star he so oli is meoa( �
/PLL_ Irl _ ` /
y Lmensed Pmfesslmml ^ -
OWNERBUILDERD
aj DECLARATION❑SWIMMING
I hereby affirThal 1 um exempt from the Commoner License Law for the
followim n
ng reomn. (Section 9031.5, Business and Plits"inns Coda: Any city or county
which mgrims a permit Ina wnstme6 akr, improve, demolish, or repair any smrcmrc
prim m it, isvuanee, also requiresdme,Theant brsuch permit to file u signed statement
Ihm he is licensed pursuant to the pr misiers ofthe Gmu-aclors License Law (Chapter 9
(commencing with Smlien7(yoxhaf Division 3 ofthe Business and Prefessinms Gde)ar
` That he is exempt therefrom and thfothxem
Ili, basis r e alleged eption. Any vimmima of
L Section 90315 by any applicant for a permit Subjects the applicant to a moil penalty of
not mnre than live hundred dollars ($500).
❑ kmnwnero dep..perty,rn my employee, with vagrants their sole semen iai.,
will do the work, and the sooemre is not intended or offered for sale (Sec. n44, Business
and Professions Code: The Comrante, Liccnse Law data nm apply b an owner of
a prepeny who, builds or improves thereon, and wltn does such work himself or through
his own employees, provided that such improvements arc not intended (ir offered for
sale. If, however. the building or improvement is sold within one year ofecmplmion,the
wnm-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ 1, as owner of the property, an exclusively contracting with licensed enntracmts to
cnnamun the pmjeet (See. 9(144, Business tad Pmfeasinnx Code:) The Conoacmr's Li-
cense
wbn contracts branch projects with a contmnurba licensed parxumn m the Careactnrs
License Law.
❑IamexemptunderSec. ,B&PCiarthisreasan
PANELS
UP'f02W AMPS
201-1000AMPS
OVHk 1010 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL'
El NEW BhDO/ADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHUR
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLET'S -SWITCHES -FIXTURES
NEW RESIDENTIAL. ELECTR SQ FT.
SQ. FE FLOOR AREA
$/SQ. FT,
TOTAL:
QTY. PLUMBING PERMIT PEE
-
PERMIT ISSUANCE
- DRAIN & VENT - WATER (EA)
Owner DateALTER
VALUATION
D f
/ (0
WORKER'S COMPENSATION DECLARATION
rfi
of I hereby ara under penalty of perjury one of the fallowing deelamtiom
have and will maintain a CertificateafCoerat to self-imure for Worker's Cnmpen-
'N jinn, m provided for by Section 39W of the Labor Code, for the performance of the
work be which this permit is issued.
f1 have and will moinmin Wmkee's Cumpemmio r Insurance, as squired by Semon
0 ofthe Labor Code. for the performance of Ilio wink for which this permit is issued.
MyWnrk' C pensatim, 1pymumz �y rand Policy nu be
Carnett j /4TF r tir¢Pch"No: I�1I140'70
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifinepermit lsfornnehandreddollars($100)
nr less)
I certify that in the performance efthe walk for which this permit is issued, l shall
nal employ any person in any manner so as to become suhject to lie Workers' Cm,Fm-
satins Laws of California. Date
Applicant I
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, CONE.
S DRIES
OCC. GROUP
TYPE CONSTRUCTION
APN
FIXTURES -PER TRAP
GAS -EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM-OVER4RIA)
GREASUINDUSTRL WASTE INTERCEPTOR
-
GREASE TRAP
BUI D DIVISION ACES
PLANCHEV
SEWER - SANITARY - STORM EA. 200 P.
ENERGY FEE
GRAD!
WATER HEATER W/OENT/ELECTR
NOTICE PO APPLICANT: If, ager making this Certificate ofxemp
Etion, you should
bombe subject 4) the Workers Comp e,rair m pmvidons of the LaN r Code, yna must
forthwith comply with such pmv6lmsstor ti,is permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work fer which this Permit is issued (Sec 3097, Civ. C)
Lender's Name
WATER SYSTBMITRBATING
SOILS FEE �V
WATER SERVICE -
`IL
PAID
Date em"a
NEWRESIDENDALPLMR. SQ. FT.
Lender's Address
1 certify that 1 have read this application and state that the name inrormmion is
sorest. l agree to comply with all city and county ordinances and state lows relating to
building construction, and hereby authorize representatives of This airy to ener upon the
above-mentioned property for inspection proposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way creme against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
TOTAL:
BUILDING PEE.
QTY. MECHANICAL PERMIT FEE •
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
pI TER OR ADD I'O MECH.
PLUMBING FEE
AIR HANDLING UNIT(TO IB000CFM)
MECHANICAL. FEE
AIR HANDLING UNIT (OVER IBOM CFM)
CONSTRUCTION TAX
Signature of ApplicanVContacmr Date
HA9C RDOUS MATERIALS DISCLOSURE
Will the applicant or Roma brildingoccupantmere or handle has.Noe, material
as defined by the Cminti n Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑Yes E]Nn
Will the applisvm m roma building necupnnl use equipment er duvites which
emit hazardous air ummmimamn as defined by the Bay Area Air Quality Management
Dian,
El Yes ❑Ne
I have road the hazardous materials requirements under Chapter 6.95 oflhe Cali-
Inmia IIea1@ &Safety Gxle, Sections 25505, 25533 and 25534.1 understand that if the
building p cumntiy haves linangthul it is my responsibility m nary the occupant
ohhe lire emswhieh/nywlrr act priorm iRuunce ofo ic�ie��n¢
rte ramourroa a✓gent /\ Dm
EXHAUST HOOD(WMUC'I)
HOUSING MITIGATION PEE
_
HEATING UNIT (TO 100,010 BTU)
HEA'T'ING UNIT (OVER 100,00 BTU)
-
PAID
Date Recempl #
VENT] LAA ']ON FANS I NOTE RESID)
BOILER -COMP (3HP OR 100,000 BTU)
IOTA; a
BOILER- COME (OVER 100,000 BTU)
AIR CONDITIONER
ISSUANCE DATE n
' -79 �IJ
ily
% Q
ISSUED BY: OQ
NEW RESIDENTIAL MECH. SQ. Ff.
TOTAL:
OFFICE