S 1583—APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPWCA"PION/IaERMIT
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I PHONE: :CONrRACIOR'SNAME:I A t WC,NOt
111F)N'rAC'I': I'IIONH:
ran) 7yCo3ll
LICENSED CONTRACTORS IIECLARAIION
1 hcmby ufGrm mut 1 are licensed under provisions of Chapter 9lcummencing
with Sac11on700pub Di 311'be lnsinessand Professions Code tmd....
. aca"' is
tall rm'c ane eBe'���
license laSS,��-n um
C
Once =1�; ?r• C il�p
ANCIII'1'IiCS DECL'I"DECLARAI'1(1N
1 understand my plans shall he used as public records
I.icenscd 1'rofmsiurot
OWNER -BUILDER DECLARA'1'IUN
I hereby affirm that I an exempt From the Commean:s Larose Law for the
following reason. (Section 7031 .5. Business and 1'n,Sessions Code: Any city .1'early
which rv,ri u Permit m amshad, alta, improve, demolish, at mpui any structure
pour to its issuance. also requires the applicant fur such vaoNi n, f ile a signed uammeal
that he is licensed pursuamOo the provisions of the Contractor's License law (Chapmr 9
(commenting with Section ]lest of Division 3 Of the Business and Promosinm Code) or
flour he is exempt tharefrom and the hods for the alleged Ise far i. Any violmian of
Section 7031.5 by any applicant fora permit subjects he oplic.nun a civil malty of
not mare than five hundred dollar (5501).
❑ I, as owner of lire ptnpeny, ur my employees with wages as Meir vote compensation,
will do the work, and the xtrudured not intended or offered for hale (Sce.71 W4,13minevs
and Professions Coale: The Cormorants License Law does net apply to an owner of
property whir huilds or improves Ihm n t, and who does such work himself or through
In,nq,loyces, novelist that web in@m en,, a immoral n offered for
sale'If, hnecver, the huilding or impmvemm�t is sold within one year of completion. [tic
t nerhuilAcr will have the burden of proving that he did not build or improve for pur-
,,scofsulc.).
F) I, asaof the pan,ray, a exclusively contracting o, ill, Iiecn.wsl tr maxna, w
nnslmcl theproject (Secs Ta14. Business and Pmlc oions Code:I The Comment"' Li -
sense Law does not apply In an owner of property who builds or improves thereon, and
who contacts for such Projects with a cuntrn'm(s) licensed p.nuunt to the Contractors
Ikea, Lax.
Ian emnapl under Sec. . B K P C for this math.
❑ Consultant Fees Paid by Applicant (Initial)
I OTY1 ELECTRIC PERMIT I FEC': I
PERMIT ISSUANCE
APPLIANCILS - RFS IDE14 IAL
PANI?LS
UPTO2OAMPS
SIGNS ELECTRICAL
"S."... 1583
SPECIAL CIRCUMMISC.
O SFDWL
TEMP. MEMR OR POI.Ii INST.
❑ ADD) ETON
POWER DEVICES
S.
SW IMM[NO POOL ELEM RIC
CONTROL#
OUT II.ID'S-SW I ICI IES -FIX'1'URIS
❑INTERIOR
NEWRESIDENTIALELI=R SQ I'P
BUILDING PERMIT INFO
I OTY. PLUMBING PERMIT I FEE I
Owner Dem
WORKER S COMPENSATION DECLARATION
I hemby aRrm under persalt, of perjury ono of the following declarations:
I lime and will maintain a CrOul' a , of Constant to self -insure for Worker's Compen-
s provided Ger by Section 1710 01 the Loan Cade, far Thu Iwrforntnnce of Ilia
k for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as requited by Section
7 )of lh. Labor Code, lot the 1111"nimtceofthework forwhichlhis purmilisissued
-
My Worker's Q( powder, inmmnc Rd Put icy nut b�r arc
Came �I al- yen 1R al' tlYLIR,IIt t..: fk 1 A/!
CIiRTIFICRll301a1IXIpMPTION OM WORKERS'
CIIMPENSAI'ION INST tANCH
(Mis%rclion need nm be completed if the permit is borrow hundred dollen (SIM)
ur It,,.)
I certify Ihail n the perharon ce if the work for which this pemtit is issued. I shall
not employ any lot in any manner so as to becone, subject ha the Workers' Congscn-
sation Laws of Califomia. Dam
Applicant I
N(yl'ICE 10 APPLICAN'll IL ,her inking This Conifivam it Emanplam, you should
became objet, u, the Wurke,s Compensation provisions at he labor Code. you nmst
hoot wA comply with such provisions or this permit shall he deemed revoked.
CONS, RUC 'I'I ON LEN OI NO AGENCY
I hereby affirm that them is a comhnaion lending agency for the peRommnce Of
the work for which this permit is iswed (Sec. 3007. Civ. C.)
IenJcrs Name
Lenders Address
I comity that I have (cad this appi cation and state that the aMme information is
correct I agree or comply with all city and county ordinances and slate laws relating no QTY.
building ceaxllacllen, and hereby nwhrd.e ne,ne,cnuolves of this coy Or enter upon'he
advise mentioned property liar inspection Pont
(We) agree to save, indemnify and keep bumdess the City of Cupertino against
Iiandhies, judgtnents, cnxls and e'pcmes which may in any way aceta' against said City
in consequence II the granting of my round.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT
SOURCE REGULATIONS.
t�11 r �i� 0 A J <- D- 9 9
signamm of nPPlicanUCnmmnor Date
HAZARDOUS MATERIALS DISCLOSURE
Will lbw e,licam or h mre building occupant store or handle h.vardous unwind
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Ilnith and Safety
Cash. Said.. 25532001
❑Yes F7 No
Will the applicant or future huilding accupmt use equipment or devices which
I h romilous It, toner unions us defined by the Bay Aremm
. Air Quality Managce
'i strict!
❑Yes El No
fourriti':heread the Mrardmi naamrads mr,jummemsunder Chapter 0,95ofthe Cali- ovrefit h Safety Cado,. Sections 25505, 25513 and 2.5534.ucmmnd Thin II' ibc
building does not currently have a tenant, that it is Illy ¢spmsibility :::11 notify tire occupmn
PI?RMIT ISSUANCE'
ALTER -DRAIN h VENT -most cx (EA)
BACK FLOW PROTECT'.. DEVICE
DRAINS-
PLUOR, BOOP U
Il%'IDRCS-PHK TRAY It•''I� IJ
OAS-EA.SYS'FEM-1 IN 41)NITS
GAS - EA. SYS'IEM-OVER 4 EA)
GREASE/UsDUSTRI. WASTE INTI 9OR
GREASETRAP
SEWER - SANITARY - STORM IiA, 210 PI.
WAIF.R HEATER W/VENT/ELECIR
WAI'17RSYS'I'I7M/IRIiAI'ING
WATER SERVICE
NEW RGSUMEN'IIAL I-I.MR. SQ. TN(
MECHANICAL PERMIT
PERMIT ISSUANCE
AUTER OR ADD TO MIiCH.
AIR HANDLING UNIT IT O I0.000 CFM)
AIR HANDLING ONE (OVER I n.(x)O CFM(
G.XHAUSI' HOOD (W/DUC17
11RATIN , ONE P (10 110,0!x) It'I'U)
IIP.ANNG UNIT (OVER PRIME) BTU)
VEN'I'ILAI'ION FAN( SINGLE BESIDE
BOILER - COMP (111P OR 100,0001311D
RUILIiR-COMP(OVIIR 100,0011TU)
AIR CONDI GONER
NIiW RLSIUIiNI'IAI. h11.CH. SQ. 171'.
OFF
JOB DESCRIPTION
"S."... 1583
NITARY NO.,
O SFDWL
APPLICATION SURM ITIA I. DAI
❑ ADD) ETON
❑ PLUM13ING Rlid'IPF
�1s W
NIC
CONTROL#
MODIFICATION
❑INTERIOR
❑CHIMNEYREPAIR
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECCH /
❑DEMOUTION
❑ ❑ LJ
JOB DESCRIPTION
RESIDENTIAL:
PIiE
O SFDWL
❑KI'fCHENRE UU1i1.
❑ ADD) ETON
❑ PLUM13ING Rlid'IPF
❑MULTI -UNIT
❑STRUCTURAL
MECHANICAL PER
MODIFICATION
❑INTERIOR
❑CHIMNEYREPAIR
IMPROVEMENT
El SWIMMING POOLS
❑ BATH REMODEIIRFPAIR
❑DEMOUTION
❑ OT HER
/r
COMMERCIAL:
❑NIiW HLDGIADDITION
❑DEMOLITION
❑TENANT'
C1 FLUID SERVICE
INIPROVEMENT
'
❑ OI'HF.R
SQ, IT. FLOOR AREA I $/SQ, IT.
PLANCHECK FEE
ENERGY ITH
GRADING ITH:
OILS FEE - to
TOTAL:
PAID
Date I0.eriplx
e
BUILDING 11 &u01 `s.
PIiE
SEISNUC Flan
O
ELECTRIC ITE
PLUMBING FEF,
MECHANICAL PER
t W 3
CONSTRUCIION'IAX
I I(IUSING MITIGAIION FEE
PAID
Date I0.eriplx
e