S 0240APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONFPERMIT PLUMBING -MECHANICAL
I Auuaess
1373 D ��-� fir•
oaks&-C.I�a/hie/(a:H°
PHONE
1 hereby affiml that I um licenwd under pnvisionx of Chapter 9 (commencing
ad0wire Seetiw70MporDirision]oOhe Bmfnmsend lRorexsinns Gam. oral mY icensa is
FUOZ in full force and effect.
GU U license Class I.ic. N
rFiaai Dam cammmm
ARCHITECTS DECLARATION
Z FO N Z I understand my plans shall M load as public amouk
OZ—a
F�F'ty Licensed Professional
(1WNER-Bl11LDER DECIARA'HON
C Q I hereby afirtn that 1 am exempt from the Contractor's I.ieeme law for the
LC,
L U following reason. (Scnion 9131,5, Business and Prnfaslnns Gala: Any city or county
31+1 y which requires a permit m construct, alter. imp®rt demolish. or repair any %trocmm
F'1=Ica prior loo-olumc. also require. Neapprem, forxucn pe.cirto rata i,md himmend
Y, lout he islie inoil pursuanno@a prcvi-ioauf In, Cnmecluls License Law Chapter
�pCOO (commencing with Section]IXMpol'Division 3ofthe Bicimessand Prafesnions Gale car
d ca
that he is exempt merefNm unit the nnFis for the alleged ummpoon. Any violadnn of
NSection 70315 by any applicant for a Moral nub mi%the applicant to a civil penalty of
urn mom man Live hundred dollars (S500).f S C D I, as owner of the pmpeny, or morh yces wire wages as bell sale conlpcnswion.
F. will do the work,and,he structure is oat Intended or offered for sale(See714. Business
a m and Pmfessoos Cock: The Commillo's License I.mv does nm apply to tic sena, nI
pmpeny who builds or improves thereon, and who does such work himadf or through
his own employees, provided that such impmvamcnu am not intended or offered for
sale. 11, however, the building or impmvemcm is %old within one year of Cumplction. the
owner builder will one the burden of proving that he did not faid or improve fon Mr -
ON ACTOR" NAMIi: LI
ob twee f
1DDRESS: S. IT
❑ Consultant Fees Paid by Applicant (Initial)
'f the progeny. am exclusively contracting with licensed contractors to
natmct the pmjat (Sm. 714, Business and Pmmsaions Code:) The Conlmnols Li
.c l.aw dies not apply to an owner of pmpedy who huiles or inlprovco motion, and QTY,
who contracts for such projects with a commctodi lieenwd Pursuant to the Comvmols
Lleenw law,
❑tum ea Munder Sc .B& P C for this reason
act
WORKERS COMPENSATION DECLARATION
traby o irm under Penalty of perjury mo of the following declandions
I haw, ane will mainmin a Ccniiam orcansenun self-inxum lar Wokce,Conhpcn-
other. as prnvieed for by Section PW of the Latin Code, for the millo mance of'ha
work for which his pennil is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
9710 of the Labor Gde, fm rho IcrRmnurec of the work for which Ihis panda is issued.
My Worker's Compensation Insurance comer and Policy number am:
Comer.I'nlicy No.:
C1WH FICATE (1F 13X1?M PHON FROM WORKERS'
COMPENSATION INSURANCE
CHis wcu n need not he completed lithe pernil is foram, hundred dollars, (Is 110)
or Less.)
I certify that in the performance of the work for which this permit is issued, I shall
mol employ any person In any runner.so as to become subject m the Worker: Campcn-
Z arfm laws of California. Doc
ZQ Applicant t
y SOL WE 10 APPLICANT: If, after making Ihis Certificate of Emoultion, you should
>become xubjccuo the WokrA Compcma0on pmvioinns of he Luton Cordo you most
forthwith comply with such pmrvisions or this permit shall be deemed revoked.
d
Uz Cat the RUC ecommtionlON NGAGBNCY
U 0 Ihemny affirm that then is aconstrvnion lending agency for the pnnmmncc of
U. H the work for which lhi s permit in issued (See. 3097, Civ. C.)
C) U lenders Name
r W Umdcr's Achim, .
1 certify that 1 have mad (his apli ialion anal none flue the uhuve Intomwni n is
fa/) correct. l agree to comply with all city unit county ordinances and alae laws relating to QTY.
�.)Z thaddingcnnnruclion, and hamby authorize remeseconives ofthis cirym enmrupm the
above mpen
red py for inspection purToms.
(We.) agree to vxc, internally and keep harming the City of Cupertino against
linhilitiu. iudgmaas. cnvm and o:eprnwe whiclh may in any wary accrue r,ainsl said City
in mmarore of he srwting ar suis Peron.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU EREGUL TIO
�� NS
Si mmofAMdeamu Cantmator Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant (it flan building occupant wore or handle hauamous material
as dcfioN by the Cupertino Municipal Code. Chapter 9.12, and the health and Safety
Calc, Section 255321x)?
❑Yes E) No
Will the applicant or future building oeupnnl use equipmentnr tevice, which
mil homrdous air contaminants as defined by the Bay Area Air Quality Maagemc'nl
UistricR
❑Yes CNo
I have read the haeurdoux materials requirements under Chapter 6.95 of the Cali -
hand, Health & Safety Code.. Sections 25505, 25533 and 255p, 1 undersand that if the
loodiny dos nut woody hmc a Icnant, their may narymuibility m .... ily the Cticupanl
of the mquiremenu which must the mat prior to Valance of a Certificate of OccuMincy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESID1!NTIAL
PANELS
UP 90201 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIDMISC.
TEMP. METER OR POLI: INST.
MWI7R DEVICES
SWIMMING POOL EI.FC'FRIC
OUTI.ETS - SWI I CHES - FI X'I ONES
NEW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMI F ISSUANCE
ALI UR- DRAIN & VENT- WATER IEA)
BACK ROW PROITC . DEVICE
DRAINS - FLOOR. PIQUE. AREA, COND.
FIXTURES - PER 'I'RAI'
GAS - EA, SYS3'I:M-I INC.4 G(J'FLEI S
GAS - EA. SYSTEM OVER 4 (EA)
GRFASE/INDUSTRL WASTE INTF.RCEP CR
GR17ASE'I RAP
SEWER - SANITARY -S'IORM EA. 210 FT.
WALTER HEATER WNEN-VELEM
WATER SYSTENU TREA9'ING
WATER SERVICE
NEW RESIDEN1 Al. PLMB, SQ. EF.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALLIER OR ADD 11) MECH.
AIR I (ANGLING UNIT' ('10 10,003 CUSH
AIR HANDLING UNIT (OVER 10 (0) C1-T1)
EXHAUST HOOD(W/DUC)
HEATING UNIT ('10 iooffix) BTU)
HEATING UNIT (OVER 1011.000 IG I-)
VENT ILATION FAN (SINGLE RESID)
BOILUR-COMP (HIP OR 100.001 BTU)
BOL LEER -COMP (OVER 1(10.010 BTU)
AIR CONDITIONER
NEW RESIDENG-IAI. MECII. SQ. IT.
OFFICE
Amus
SQ. I'1'. FEO( '19RjA
0
/2�1f//�
FEE�O"eA4
❑
TYPE CO:
BUILDING PERMIT INFO
BI -DG ELECTVIARA 1 MECH
1
FEE
1013 DESCRIPTION
RESIDENTIAL:
CSFDWL1 ITCHEN REMODEL
❑AUDITION CI'.UMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MOIIIFICAHON
C INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT CSWIMMING POOLS
TH RESIODEUREPAIR (]DEMOLITION
OTHER
BUILDING DIVISION FENS
PIANCHECK FEE
ENERGY FEE
GRAVING FEE
COMMERCIAL:
CNEW BLDG/ADDI'11(1N ❑DEMOLITION
CTESIAN'I' CFOODSERVICE
IMPROVEMENT
❑OTHER
PAID
SQ. I'1'. FEO( '19RjA
0
/2�1f//�
FEE�O"eA4
PAID
Oalc RccciplM
TO'T'AL
ISSUANCE DATE
STORIES
TYPE CO:
OCC. GROUP
1
BUILDING DIVISION FENS
PIANCHECK FEE
ENERGY FEE
GRAVING FEE
SOILS IPE
PAID
RccciplN
TOTAL:
BUILDING 713
FEE
SEISMICEE
Id ECT IC FEE
piste RING E iI:
PAID
Oalc RccciplM
TO'T'AL
ISSUANCE DATE