S 1297I
'a
— APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
+ I BUILDING DIVISION
PUILUING ADDRESS:
APPLICATIONIPERMIT
PHONE.
:vo e0
❑ Consultant Fees Paid by Applicant (Initial)
I,ICENSF.DCONTRAMURS GLCLAHAf[ON QTY
1 Witch, affirm Nat 1 an, licensed under provisions nl' Chapter 9 (commencing
40Cwith Sesdan 7000faf Division 3 of the Business and Professions Cock, and my license is
YI- in full furevand' f 572762 �.
G V V License Class Lic, p
>mo Convo i
�y ARCHITECTS DECLARATION
'o n Z 1 understand my plans shall be used ns publ is enols
Z�Q
-F'-W Licensed Prefessinntil
OWNUR-BUILDER DECLARATION
C W 6 E hereby a1Rm, that 1 am exempt from the Cantmgmre License Law for the
d V following mann. (Section 7031.5, Business and Professions Cole: Any city or county
which requites h, pemtit to construct, alter, improve, demolish or repair any structureµOe
..1 primm it, ix,mme,al.snrequiai applicant lorm,lb permit m Gleasigncdsmement
E} that he is licensed pursuant to the provisions of the Committers License Law (Chapter 9
X00 (commencing with Seetion 7000) at Division 3 of the Business and Professions Code)or
Wn that he is exempt therefrom and the basis for the alleged exemption. Any violation of
--, Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
t more than rive hundred dollars (8501).
0 ❑ 1, mower of the pmpeny.nr my employ«s with wages as their sole compensation,
will do the was, and the Novation is nut intended or nOmed for sole (S«. 7U44, Business
L and Professions Code: (fie Containers License law does not apply to an owner or
property who builds or improves thereon, and who does such work, himself or through
his own employees, provided that such improvements am not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
eerer-builder will have the burden of proving that he did not build or improve for pur-
,soac of sde.).
i, as owner of the property, am exclusively contracting with licensed contrachms m
consumer he project (S«. 7tN4, Business and Professions Cale:) The Contractors LI -
se law does not up,Fy to an ownot of property whe build, or intranets thereon, and QTY
who contracts for such projects with a contractor(s) licensed pursuant o the Contractors
License Use
I am exempt under Sec . R k P C for this reason
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 20P AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCLE UMISC.
'ridsup. MGfIift OR MOLE INST.
POWER DEVICGS
SWIMMING POOL ELECTRIC
OUTLETS - S W ITCHES - FEXI'U RES
NEW RESIDENTIAL ELECR SQ PT.
Owner Date
IIIM WORKER'S COMPEJSADON DECLARATION
1 hereby aOour undo penalty of perjury ane of the following divisnaions:
1haveandwillmaimmua Ccmficme of Consents self-insurefarWorker'sCmnpen-
sution, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this Permit is issued.
❑ 1Investor will maintain Worker, Compensation Insurance, as required by Section
3700.1 the Lobm CC�akhe. far the performance of the workyf.. which this pecan, is issued.
My
Rw,:r"�oltr IGlsaln3=,. c,am Pal Y lwx r t9 9
CEIYI'IIICATIi OP Ii%EMI'I'ION PROM ORKERS'
COMPENSATION INSURANCE:
(this section need not he completed If the permit is Intone hendreddollami$10 R
or less.)
I certify Not in the performance oftbe work for which Ibis Permit s issued, l smell
not employ any person in any manner m a at b«ron,e .subject, the WorkersCompen-
z cation Lows of California. Dam
z Applicant
NGHCE TO APPLICANT. If, after making this Ceniliena of Exemption, you should
F become subject to the Wmker'n Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this pmnit dull he deemed mvoked.
d A
CONSTRUCTION LENDING AGENCY
Li l hurchy.fifirmwhihhipermitrcissued(ev, 30lending agenryriot N<perfomanee of
Hthe work for which this permit is issued (S«.31y17, Cit. CJ
O 1.i Leader Name
,r H.1 lender's AdW,codify
(A I certify than I have read this city
and coon and latdine that Be shove laws
res ing is
IU+N cmea.Iagree
mnatcomply with all cityand countyotdinonees.and sea lowsrelatingto QTY.
U Z buese-imotimed oopen herchyamhonp represemwives of this city to cmcr upon 0m
move" (We) 9 pm sat" for inspection purposes.
(We) agate to cove, Indemnify and keep harmlcan Ne City accrue
against
Iiaconsequ consequence
of the
and expenses which may In any way accrue aguin.0 said City
in nLICANT of the Rooming Sthispermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON8OINT
SOU REGULATIONS.^
J�--//,�•s Z -2e yrs
Signewreal Applicreal tracer Dom
HAZARDOUS MATERIALS DISCLOSURE."
Will the applicant or future building occupant sem or handle hvandous material
as leaned by the Cupertino Municipal Code, Chapter 9.12, and Ne Health and Safety
Code, Seedon 25532(u)7
❑Yes C] No
Will the applicant or Ihmre IwilJin6 occupant me'
or devices which
tit hoN
mous air ummminunu as defined by rhe Bay Area Air Quality Munagemem
mine"
❑Yes E] No
I have read mortician he materials nN uiremeres under Chapter 6.95 of the Cad -
i man Health & Surety Code, Sections 25505, 21533 and 25534. 1 understand that if the
Wilding docs not currently have u tenant, than it is my responsibility to notify the «cupant
or the requirements which must be met prior to issum en ma Certificate of Oceupomy.
PLUMBING PERMIT
PERMIT' ISSUANCE
AI TER - DRAIN & VIisi WATER (HA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURIS - PER TRAP
GAS -I?A. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM"OVER 411.AI
GREASEANDUSTRI. WASTE? INTERCEPTOR
GREASF.TRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATCH HF.AITR W/VENT/ELECfR
WATER SYSTEM/THIiATING
WAFER SERVICE
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,010 CFM(
AIR HANDLING UNI "T (OVER 10,000 CFM)
EXHAUST HOOD OVIDUCT)
REATINC. UNIT (TO 110,000 BTU)
HEATING UNIT (OVER d)(L" BTU)
VENTILATION PAN (SINGLE RESIDE
BOILER -COMP (3HP OR 1 W,M) BTU)
ROILER-COME' (OVER 100,000 RTID
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. FT.
FEE
1297
Z
N JOB DD-FSCRIPTION
RESIDENTIAL
❑SFDWI.
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
❑MULTI -UNIT
[]STRUCTURAL
MODIFICATION
El INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
[ISWIMMING POOLS
❑ BATA REMODEL)REPAIR ❑ DEMOLITION
❑ OTHER
COMMERCIAL:
0 N17 BLDG/ADDITION 'MOLITION
❑TENANT FOODSERVICE
IMPROVEMENT
❑ OTIBiR
SQ, ET. FLOOR AREA
PAID
FEB 24
STORIE�� �TY
PLANCHECK FEE
ENERGY FEE
GRADING FTE..
SOILS FEE
PAID
Date
BUILDING HE
FFE SEISMIC FEE
ELECTRIC FEE
PLUMBING HE.
MECHANICAL F Efi
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt p
TOTAL:
TOTAL:( (ISSUED BY:
FICE