S0001C0420APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING - F. FCII RICA(. PIiRMIT 0 A /5 0
BUILDING DIVISION'
APPLICATION/PERMIT rnr.11,c1 „NIL A+Enn+vTn,r1..1... SOOQI 4 L
IOmM
I hereby affirm that I am licensed under
with Section 7000) of Division 3 of the Business
in full force and 4*Aj _ n,
Jc_ (sT0AtlI Or 64
CONTRACfOR'S NAME: LIC NO:
cam.
:-that: x 7� �F6�Fri
❑ Consultant Feces Paid by Applicant (Initial)
9 lcumntencing QTY ELECTRIC PERMIT FEE
nit myli«ntt is
PERMIT ISSUANCE
I i A S APPLIANCES—RESIDENTIAL
Nab ARCHITECTS DECLARATION
F y z I redamu
umd my plen,,hall be used as public rends
-zz-=
1 3 t: YI Licensed Pmfessi... I
OWNER -BUILDER DECLARATION
C C ¢ I hercby .IEm, that 1 ain exempt fan, the Contractors license Law for that
Ow
H lonowing reason. (Section 7031.5, Business and Profess..... Cure: Any city ser county
N which requires a permit to construct, ahnr, :.. m
prow, demolish. nor apoir any stmcmor
F. f�ONJ priono it, i ... note. Oil ....... e,nhcapplicant fasten permitto file. signed Imanent
Fply that he a liccnad pre,mmno'he Pmvismns nflhe Contractor's License Law (Chapter 9
LL��O (commencing with Section 9000)of Division 3 of the Business and Professions Cure) or
d d c C that he is exempt therefrom and the M1asi, for the alleged exemption. Any violation of
X m_ LL Section 7031.5 by any applicant for a Permit subl«ns the applicant to a civil penally of
W N not more than five hundred dollar, (S.900).
1- ] 1, as owner ofthe propcny.or my employees with wages as their sole compensmlon.
F will dnihe workand theatmctomis.. intended oroRered for sale (Site. 70cU Business
W3 m and Profession, Code: TM Commmor's License Law dws not apply m an ..wnor of
pmpeny who M1uild nr nnprovcv thereat.., and who docx eb work hlmsel.... through
his own employees. provided that such impmvemems am not intended or offered for
sale. If, however, the building or improvement is sold within ane year of cnmpinion, the
cr-builder, will have the hard,,, of proving that he did oat build or Improve lin pap
pnc of 4e).
❑ L as awner of do "'pen, am exdusively ronumting with licensed contras.., m
construct the project (Sec. 9014, Business and Professions Codd) 9Tc Contractor's Li-
cnwLaw dace,a not apply to an owner of jur,wny who hailds or improves them ... ,and QTY.
who contracts for such projects with a conbamor(s) licensed pursuantto the Contractor'.s
License law.
I am exempt under Sec. . B & P C for this mamn
PANELS
Oil r020OAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TG1E METER OR POLE INST.
M)WF.R DEVICES
SWIMMING POOL ELECTRIC
OU'I LETS — S W ITCHIiI IN,
NEW REMDENTIA
Owner Date
WORKER'S COMPENSATION DECLARATION
pp I hereby affirm under penalty of perjury one of the following dedamtio.,
G11 have and will malmain a Cerli Ileac of Consent m sdf-insure Pix Worker's C'..mpen-
`\, b "cation, as provided for by Section 3900 of the Labor Calc, for the p:rftumaace of the
work for which this permit is issued.
1 have ..it will maintain Worker', Compensation Insurance, as required by Section
390(1 of the Lubar Celc, far the perfurnmuce al the work for which this permit is issued.
Cardenrkci nm
CERI IFICATE
x a17 EXEMiFI]ON FROM
M nWORKERS ORKiRS
COMPENSAT N INSURANCE
(Thissecton n«dnm Mcompletedifthepmitisfarunehunded'
dollaf
(5100)
or less.)
I ccrtlfy That in the p:rfnrmmnce n[thn work far which thlupermit is,Ired, I shall
not employ any Pamir in any manner ygc 1 pr�pm IlfMltrrtheWorker,Compen-
Z .Orion La fCal�; _
zO Apprean��� i./4��
NOTICE 10 APPLICAM: If, ahs nr king this Camillo, of Emoulfi n, you uboom
1•' become subject to the Worker's Compensation previsions of the Labor Cade, you mint
Wforthwith comply with such provisions or this permit shall be deemed revoked.
0
Cf1Nhem is aI ION LENDING ng agency
U 0 1 hereby which
histhat
Kneere Is. sed (See on lending agency for the performance of
0.H the work far which this permit is issued (Sec. 309, Civ. C.)
OLcndcr, Name
U
rLenders Address
6. 1 ccneY Nat 1 have real this application and sate that the above information is
UZ amecn.lsgrccmcomply
.andwith all city and dmmyoomi1c, oranddinances Into, eructation
relatinghe QTY.
V Z M1nilAing conatmctinn, nnA herehy n.thnrizc rcpresenmtives of rho tiny memmtamun the
above mentioned property for inspection purposes.
(We) agree u, save, i cemnify and k«p hamdccs rbc Cryof Cupertino against
Iiehilitics.judgmentIx., ad espemes which may in anyway accrue against said City
immrcc,rcnccnfnhc1 ninguft 's Onion.
APPLICANJ' UND :'I'A - r D PLY I'll ALL NON -POINT
SOURCE R 10'
Signa pp kcal ..east
IIA! DOUS MATERIALS DISCLOSURE
Will the apdicmu or future building oeeupat l "I'm ,, handle hamrdous mammal
w defined by the Cupcn Inn Municipal Code. Chapter 1).12, and the Health and Safety
Cade. Section 25532(x)'!
❑Ycs �Nu
Will the applicant or future building occupant sex equipment or devices which
emit bzaard,ms air contaminants as defined by the Bay Area Air Quality Manogercem
District?
❑Yes K?No
I havc rod n/hj,rdour —ala rc mmems u r Omprer 6.95 of rhe Cali-
ySm5052foma Health & So 533 and' 534. 1 understand that if rhe
SQ FT.
PLUMBING PERMIT /FEEE�
PIiRMIT ISSUANCE 3
ALTER—DRAIN & VENT— WATER IEA)
BACK FLOW PROTECT. DEVICE
DRAINS — FLOOR, ROOK AREA. CONI(,
FIXTURES — PER TRAP
GAS — EA. SYSTEM -I INC. 4 O(11'LETS
GASB— EA. SYSTEM -OVER 4 (EA)
GREASE/I N DUS'TRI. WASTE INI FRCEPIDR
GRF.ASETRAP
SEWER—SANITARY—STORM EA. 200 FI'.
WATER HEATER WNEbT/ELECTR
WAI'I7R SYS I'17M/ REA'I'I NG
WATER SERVICE
RESIIIENIIAL PUMB. SQ. 14.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO IRp)O CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EX FAUST I[00D I W/DUCT)
HEATING UNIT (TO 10X1,000 BTU(
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER—COMP (3HP OR 1 00.000 BTU)
BOILER —COMP (OVER 1 M,M) BTU)
AIR CONDITIONER
NEW RES IIIENTIAL M ITCH. SQ. PT.
OFFICE
FEE
f
J
I BLDG ELECT PLUMB MECH
tl ED 1:1 ISI ❑
JOB DESCKIPI ION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN REMODEL
❑AUDITION
[I PLUMBING RE -PIPE
[I MULTI -UNIT
El STRUCTURAL
MODIFICATION
[I INTERIOR
❑CHIMNEY REPAIR
IMPROVEMFNf
0SWIMMING MOUS
❑ RAM REMOD 1/REPAIR ❑ D? 01.1'HON
i i�7x.e
o f <
/�Fd'i7�K
7S
/-•_n i r na 1
-x13
COMMERCIAL:
❑ NEW BLDGIADDITION
❑ DEMOLITION
[]II; NANT
❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
VSQ.
S IOR IIS 'I'YPECONSTRUCUOh
BUILDING DIVISION FEES
PLANCHECK ITE
ENERGY FEE
GRADING ITIS
5( IIS FEE
PAID
Date Receipt 8
BUILDING FEE
SEISMICEFFE,ELECTRIll '1PLUMBI ,JUMECHAECONSTRTAX
HOUSING MITIGATION FEE
DATE