S 0035APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
rrmv nc rnoco•Prtun BUILDING - ELECTR
BUILDING DIVISION APPLICATIONMERMIT
lofe(p COL430T 1-i1LLS L_&)
INER'S NAME: PHONE:
K4 a-"anlrek 2S2 -8Z
❑ Consultant Fees Paid By Applicant (Initial)
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contramors License law for the
following mama (Section 7031.5, Business and Prefcomns Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any swemre
prior m its issuance, alta requires the applicant fur such Fe.an. file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt themimin and Ne basis for the alleged exemption. Any violation of
Section 703 L5 by any applicant for a permit subjects the applicam m a civil penalty of
not mum than rive hundred dollars ($510).
1, as owner of the progeny, army employees with wages at their sole compem ttion,
will do the work, and the stmcture is not intended or offered for sale (Sec. 70,14, Business
and Professions Code: The Commctor's License Law does not apply to an owner of
property who builds nr improves thereon, and who docs such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building ar improvencia is sold within one year of completion, he
ne,taiilder will have the burdem of proving that he did not Wild or improve for pun
Pse it side.).
FI 1, ax owner of the prnpedy. um exclusively contracting with licensed crmracmias m
construct the project (Sec. 7014, Business and Professions Cale:) The Co.,..,'s Li-
cense Law does not apply to an owner of property, who builds or improves thereon, and QTY,
who nwcts forsuch projects with a contivants)licensWp th
Lice. (� T
❑ 1 apt t under Sep. �1 HT in ns real
Dam
SIGNS ELECTRICAL
SPECIAL CIRCUI F MISC.
TEMP. METI2R OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCI ES—FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
IVr 1 hereby affirm under penalty of perjury one oPthe following dectmaaons:
❑ IM1ave anJ will main.ina Certificate ofCnnsent to selGinsure for Workels Compcn
summa, as pinside for by Section 37W of the Lahr Code, for the peRammnce of the
work for which this permit in issue.
1 have and will mafnmin Worker's Compensation Insurance, ns require) by Section
37M of the IalsorCode, for the performance of the work In wh'mh Nis pemtit is isnucJ.
My Workers Compenmtion Insurance eamler and Policy number are:
Cameo Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This nuanced not beeompivied ifthe permit is intone hundred della. (51 W)
or les'.)
I certify that in the performance of the work for which this permit is issued, i shall
not employ any Person in any manner so as to became subject to the Workers Compen-
,Z 'alien Laws of Cull Tema. Date
Z O Applicant 1
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
a�Mconte subject m the Workers Compensation provisions of the Labor Code. you must
Dafrodoe b comply with such provisions or this permit shall W deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a constmction lending agency for the performance of
the work for which this permit Is Issued (Sec. 3107. Co. C.)
0 lender'Name
D.1 Lender's Address
LSs 1 certify that 1 have read this application and state that the above information is
V1 correct. 1 agree to comply with all city and county ordinances and state laws relating to QTY,
(„) Z building construction, and hereby authorise representatives ofthis city m enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hurnleas the City of Cupertino against
liabilities.judgntents, costs and expenses which may in any way acerae ugainnt said City
in consequence of the granting of this Fauna.
APPI(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
HAZARDOUS MATERIAISCLOSURE
Will eche applicam or fmurc huiiding oeap tore or handle hazardous material
as defined by eche Cupertino Municipal Code, Chapter 9. L2. and the Health and Safety
Code, Section 25532(a)?
❑Yes 0 N
Will the applicant or forum holding occupant use equipment or devices which
Molt hazardmis an contaminants as defined by the Bay Area Air Quality Management
ocullo't
❑Yc' ON.
I have read the huzardnus manorial, requimmems under Chapter 695 of the Cali-
fornia'Health At Safety Code. Sections 25505, 25533 it 25534.1 understand Nat if the
huiiding does Out currently have .,,a.m. then it is my mspo iclifliay m notify the rccupa s
of the ox ma mama which must be stet pion m issuance of a Cenificme of Ocxupancy.
PLUMBING PERMIT I FEF.
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER (E
It
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF, ARE OND,
FIXTURES - PER TRAP
GAS - EA. SYSIT.M-I INC.4 OUT
GAS - EA. SYSTEM -OVER 4 (EA)
GREASWINDUSTRLWASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WIVENVELECfR
WATER SYSI'EM/IREATING
WA'I'ERSERVICE
NEW RESIDENTIAL PL.MB. SQ. 14.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD ( WIDU W)
HEATING UNIT (TO 110.01 IFFU)
MEATI NO UNIT (OVER 100.1100 RTU)
VENTILATION PAN (SINGLE. RESID)
BOILER—COMP CIIIP OR I W.Of10 BTU)
BOILER—COMP (OVER 100,000 RTU)
AIR CONDI GONER
NEW RESIDENTIAL MECH. SQ. FT.
C
4 Zi 1•l%
INFO
' JOB DESCRIPTION
TPA) 1C� 'PEA14�* q4'G-38%
❑ KITCHEN RB10DEL
LICENSED CONTRAC7(3R'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section70011 Division 3 ofthe Business and Professions Code, and my license is
in fun force and effem
License Class Lick
Dae Conte
QTY. ELECTRIC PERMIT
PERMIT ISSUANCE
yQD110O
FSE
�VV
N d
APPLIANCES—RESIDENTIAL
I,,, p y
b v�2,7J.
ARCHITECTS DECLARATION
I understand my pians shall be used as public rcnndz
PANELS
UP TO 201 AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contramors License law for the
following mama (Section 7031.5, Business and Prefcomns Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any swemre
prior m its issuance, alta requires the applicant fur such Fe.an. file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt themimin and Ne basis for the alleged exemption. Any violation of
Section 703 L5 by any applicant for a permit subjects the applicam m a civil penalty of
not mum than rive hundred dollars ($510).
1, as owner of the progeny, army employees with wages at their sole compem ttion,
will do the work, and the stmcture is not intended or offered for sale (Sec. 70,14, Business
and Professions Code: The Commctor's License Law does not apply to an owner of
property who builds nr improves thereon, and who docs such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building ar improvencia is sold within one year of completion, he
ne,taiilder will have the burdem of proving that he did not Wild or improve for pun
Pse it side.).
FI 1, ax owner of the prnpedy. um exclusively contracting with licensed crmracmias m
construct the project (Sec. 7014, Business and Professions Cale:) The Co.,..,'s Li-
cense Law does not apply to an owner of property, who builds or improves thereon, and QTY,
who nwcts forsuch projects with a contivants)licensWp th
Lice. (� T
❑ 1 apt t under Sep. �1 HT in ns real
Dam
SIGNS ELECTRICAL
SPECIAL CIRCUI F MISC.
TEMP. METI2R OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCI ES—FIXTURES
NEW RESIDENTIAL ELECTR SQ FT.
IVr 1 hereby affirm under penalty of perjury one oPthe following dectmaaons:
❑ IM1ave anJ will main.ina Certificate ofCnnsent to selGinsure for Workels Compcn
summa, as pinside for by Section 37W of the Lahr Code, for the peRammnce of the
work for which this permit in issue.
1 have and will mafnmin Worker's Compensation Insurance, ns require) by Section
37M of the IalsorCode, for the performance of the work In wh'mh Nis pemtit is isnucJ.
My Workers Compenmtion Insurance eamler and Policy number are:
Cameo Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This nuanced not beeompivied ifthe permit is intone hundred della. (51 W)
or les'.)
I certify that in the performance of the work for which this permit is issued, i shall
not employ any Person in any manner so as to became subject to the Workers Compen-
,Z 'alien Laws of Cull Tema. Date
Z O Applicant 1
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
a�Mconte subject m the Workers Compensation provisions of the Labor Code. you must
Dafrodoe b comply with such provisions or this permit shall W deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
1 hereby affirm that hem is a constmction lending agency for the performance of
the work for which this permit Is Issued (Sec. 3107. Co. C.)
0 lender'Name
D.1 Lender's Address
LSs 1 certify that 1 have read this application and state that the above information is
V1 correct. 1 agree to comply with all city and county ordinances and state laws relating to QTY,
(„) Z building construction, and hereby authorise representatives ofthis city m enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hurnleas the City of Cupertino against
liabilities.judgntents, costs and expenses which may in any way acerae ugainnt said City
in consequence of the granting of this Fauna.
APPI(CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
HAZARDOUS MATERIAISCLOSURE
Will eche applicam or fmurc huiiding oeap tore or handle hazardous material
as defined by eche Cupertino Municipal Code, Chapter 9. L2. and the Health and Safety
Code, Section 25532(a)?
❑Yes 0 N
Will the applicant or forum holding occupant use equipment or devices which
Molt hazardmis an contaminants as defined by the Bay Area Air Quality Management
ocullo't
❑Yc' ON.
I have read the huzardnus manorial, requimmems under Chapter 695 of the Cali-
fornia'Health At Safety Code. Sections 25505, 25533 it 25534.1 understand Nat if the
huiiding does Out currently have .,,a.m. then it is my mspo iclifliay m notify the rccupa s
of the ox ma mama which must be stet pion m issuance of a Cenificme of Ocxupancy.
PLUMBING PERMIT I FEF.
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER (E
It
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF, ARE OND,
FIXTURES - PER TRAP
GAS - EA. SYSIT.M-I INC.4 OUT
GAS - EA. SYSTEM -OVER 4 (EA)
GREASWINDUSTRLWASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER HEATER WIVENVELECfR
WATER SYSI'EM/IREATING
WA'I'ERSERVICE
NEW RESIDENTIAL PL.MB. SQ. 14.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD ( WIDU W)
HEATING UNIT (TO 110.01 IFFU)
MEATI NO UNIT (OVER 100.1100 RTU)
VENTILATION PAN (SINGLE. RESID)
BOILER—COMP CIIIP OR I W.Of10 BTU)
BOILER—COMP (OVER 100,000 RTU)
AIR CONDI GONER
NEW RESIDENTIAL MECH. SQ. FT.
C
4 Zi 1•l%
INFO
' JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL
❑ KITCHEN RB10DEL
ADDITION
O PLUMBING RETIPE
MULTI -UNIT
OSTRUCTURAL
STORIES isTYPE
(CC. GROUP
1z 3
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATH REMODEL(RF.PAIR C DEMOLITION
OOTHER
COMMERCIAEINEWL
❑TTN 4/A�DJ106 ❑FWOLITION
DSERVICE
IMPROVEMENT
OOT
4.F.
I UTAL:I TISSUED BY:
OFFICE
44'Z
VALUATION
STORIES isTYPE
(CC. GROUP
1z 3
CONSTRUCTION
APN
3S9 28-01
FEES
�t#
VISION
TOTAL
BUILDING FE
FEE
SEISMIC IEE Z
ELECTRICFl
PLUMBING JEE p
MECHANIC fE PEP
CONSTRUCTION\X
HOUSING MITIGATI N FEii
PAID
Om Reapt k
_
I UTAL:I TISSUED BY:
OFFICE