288872APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
RUILDING PROJECT IDICNTIFICA'ITON
PERMITNO.
2 87
'
DUILDINGADDRESS: / '
s
SANITARY NO.
APPLICATION SUBMITTAL DATE
as
11,6
6CAROLMA
'OW
MNAME: . - 1
U -P 6o PH( I?:
D
NA; TON'SQIAMI?: LIC NO
NIC
❑
' '
ARCHffECT/ENGINF.P.: LIC NO,'
ADDRESS:
i Q
CONTACT: _ PHONE:
yob �a 4868
❑ Consultant Fees Paid by Applicant(Initiap •
13VILDING PERMIT INFO
BDG . ELEcr PLUMB MF:CH
❑ ❑ o
LICENSED CONT'RACTOR'S DECLARATION
1 hereby affum that I em licensed under provision of Chapter 9 (commencing
with Section701R)Of Division 3ofthe Businessand Professions Code, and mY license is
in full free end effeyl/ ^
LicenscC W !�_. Lic,p 8 20 /5, S / .
Date '� Comrve�
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
QTY ELECTRICPERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
'
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDITION El PLUMBING RE -PIPE
C1 MULTI -UNIT ❑STRUCTURAL
MODIFICATION
+
❑ INTERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH RFMODEUREPAIR C1 DEMOLITION
❑ OTHER
PERMI'I'ISSUANCI? -
APPLIANCES -RESIDENTIAL
PANELS
( ..
UPT0200AMPS
Licensed Profeuimnal -
OWNER-BUILDERexemptm Ce RAI Cmilecu
I hereby affirm that 1 am exempt the Commemr. License Law for the
following reason, (Section 7031.5, Bu,io5as and I'ntfico e, Cole: Any city or county
which requires a permit to construct, alter. improve, demolish, or repair any structure
P.ionuits issonn<e,nFn reyuircs the applicant fur such perm's.. fileasigmd,burawn,
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(comencing with Section 7") of Division 3 of the Business and Professions Code)or
Ihat hme ie exempt therefrom and the basil for the alleged exemption, Any violation of
Stttinn 7031.5 by ry appiicrt faro permit subject the epplicanuovcivil pcnehy o!
Tot marc than five hundred doll...($500).
❑I,azownernf We propcny. or my employces with wages as their sole compensation,
will do the work, and the structure is not intended oroffered for sale (Sec. 7014. Business
and Professions Code: The Contractor's License law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provide that smh imprnvemcros are not intended or affiard1o.-
sale. If, however the building or improvement issold within one year of completion, the
roact-huildar have the burden ofpr.. in, In., he did not tui to or improve for pa,.1
posecfsale.).
❑ 1, as owner of the property, am exclusively contracting with licensed commemrr toI-'
nmatruct the Pmject(See 7044, Bnincsined Pma,sions Code:) The Contractor'.,Li.
censee Law does not apply to an owner of property who builds or improves thereon, and
who contract, fur such projects withn contractor(s) licensed purss:am to the Contractor's
License law. -
1 am excmplundcr Sec. R & P C for this reason
2111-I(kIOAMI'S
OVER lapAMPS -
SIGNS 13LECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE INST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLIII"r�
EITENANT ❑FOODSERVICE
IMPROVEMENT, ,
❑ OTHER
,
POWER DEVICES ',
SWIMMING POOLHLECTRIC
()OTLI?'1'$- SWITCHES -FIXTURES
s
NEW RESIDENTIAL. ELF.CfR SQ FE
'
SQ. IT. FLOOR AREA
-
{�
OC/
$/SQ. FT.
1, y
QTY. PLUMBING PERMIT FEE.
PERMIT ISSUANCE.
ALTER - DRAINA, VEST -WATER EA)
BACK FLOW PROTECT. DEVICE
Owner - Dutc
L%ry- _Aaa V!y}!kl{A/TION
'�J�/S
�VP•i-r • ,•
I WORKER'S COMPENSATION DECLARA'T'ION -�
1 hereby affirm under pe.ahy of perjury ane of the fallowing dedamtiom:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compco-
'.ion, u Provided for by Section 37M of the Lahr Cole, for the per ce of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by S tion
J7fpof the lahorCale,fonhe performance uhhe work forwhich this peen's is is. tW.
My Work Com nstei ffti ace corricrund Policy,? ac I /
Carricr IUI lIt -Policy No,: 4f/ i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPIMATION INSURANCE
(This section need not be completed ifthe permit is forum hundred dollars ($1 )
orless.)
necaf the work forwhichthispcmmitisissucd,ish It
I certify thetiKn,
not employ any .,aner macro become suhjtttmthe Workers Comlx r-
soden laws of Calif
Applicant
DRAINS- FLUOR, ROOF, AREA, COND. -
STORIES sf/
' Y�
TYPE CONSTRUCTION
r
-
FIXTURES - PER TRAP
GAS-LA.SYSTEM-1 INC.4011TLET5
OCC. GROUP
-
APN
'
-
GAS -EA. SYSTEM -OVER 4'Ui%)
❑I(F.ASInNDI1STRI. WASTE INTE fiPTOR
BUILDING DIVISION PHIS
GREASETRAP -
PLANCHECK PER ,
Is
SEWER -SANITARY -S RM I?A.2W FT.
ENERGY FEE
GRADING PER
-
WATER HEATiRW /ELECTR
NOTICE TOAPPL'ANT.If,mr,anakin thi. Ceni ate nl' 1?xemption, ynJy{ord
become subject los eWorkers mpcnsminn of the La4rt CCCCCCppppppppIIlI pp__u ruts
fonhwhheomply its ucM1 pr t l �r n be deeme"Irif,
//
CDT. Ilton. LE )I QG
Ihercbya irm that Cher 'uconsu ct Ic ng ency for �
the work for whi this permit sued (Sj:.tiv, C.3
laude.'. Name
WATER SYSTE 111sATING
SOILS FEE
-
PAID
Date •1 R 'eito
tWATRR SF ICE +
NEWSIDI?NTIAh PLMa. SQ. IT.
_
T(YI'AL:
Lenders Addie.
TOTAL:
BUILDING FEE
1 certify hm I have retW this application and a that the aMwe information o
correct. I agree o comply with all city and cru ordinances and stale laws relating to
buildargconst ction,and ha -to authorise bessimin,esel9hischy memerupanthe
.lave -madden prnpeny l'o ..... i .posses.
(We)ng an n cep clen the City of Cupertino against
incoilies,j m .,arse hie any in any way scene against said City
incense enceo a gof nn'. -
APPL ,ANT Df Tr D D tLL COMPLY WITH ALL NON -POINT
SOI' CPR F .0 I) N
QTY• MECHANICAL. PERMIT I PIE
SRISMICP
ELEMRIC
P13RMITISSUAN6i 11
-. ALTER OR ADD TO MUCH.
PLUMBING FNP.
'. AIR HANDLING UNITOO 10,(X10 CFM)
MECHANICAL FEE
UNIT (OVER Ia,(IW )
CONSTRUCIONTSlgnvmmol'Applieant(Contracmr
hate
,SURE'HOUSING
Will theopplicant or future cupant score m handle hazmdous materialT(To
as defined by the Cupertino Municipal Code, Chapter 9.12, and the licxlth and Safety
Cade, Section 25532(x)?
❑Na
the applicant ser future building by the B use equipmentof Ma na ementemit haaardous sir cmmaminnms as defined by the Boy Arca Air Quality Management(JHP
District?-
❑Yes [3 No
t 3 -
I have read the haunlous materials mquirtmrnts under Chapter 6.95 of dm C.li-
humin Hcahh & Safety Cole, Sections 25505, 25533 and 25534. 1 undersand that if the
haildln dors not currently have a terns, that it is rte
g Y Y ofaCelitynsnotifythepeary.
of the iequirement which must he met prior to issuance of a Certificate of Occupancy.
OD GAIMUCT)HAZARDOUS
MITIGA N1 FEE
100,0(11 TO)
WUNIT-
IT(OVER ),00013111)❑Yes
.PAID
FA INGLE RESID)
-Wnd
OR I(p.0110 BTU)
,
TOTAL:
NOILIiN-/MP (OVER FalRTU)
/
AIRCDITIONER
ISSIIA CE D E
ISSUED BY: tat
s
NE R,SIDENTIALMECILo. SQ, PT.
Owner or authuriud agent Data
s TOTnL:
:OFFICE