99120058APPLICANTTO FILL IN INFORMATION WITHIN RED LINES
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT �.
B i1 I,DING A DURESS',
IAll�l'T.-.- --- , n_r- 2u.
BALL POINT PEN ONLY
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION QTY
I hereby affimt that 1 am licensed under previsions of Chapter 9 (connttencing
DOwith Satins l(Xp)nf Division 3 of the Business and Professinnz Care. andrnylimnscis
W F in full lone and effect.
Urs Liccnnc CIa,, —L,c.#
ARCHITECTS DECLARATION
~ r=/l Z 1 undemwnd my Elam mall be used m public records -
OZN0
QF; Licensed Profnsiowl
a5', OWNER -BUILDER DECLARATIONa Q I leachy a11Mn than I ant escmpl Poon the Commctor'e Liao, Law Ila ins
X3. U following reason, (Sectio, 1031.5, Business and Professions Code: AnY coy or ennnry
W � a y which requires a permit to construct. alter, improve, demolish, or repair any structurex 01 prior to issuance.also requires the applicant for such permit in file a signed statement
% as that he is licensed formula to the provisions Of the Contractors License Law(Chap ef9
G� (commencing with Section IlXXBof Division Sof the Rumors, and l4nfcsuons Calc) or
C. p� o CL that he le crempt therefrom and the bnaiv lin me n11cgN exmnpt nn. Any vialntion of
W .. ce Section 1031.5 by any applicant fora Itcnah subjects the npplica a to a call,enahv Of
not more than for hundred dollars (S500).
SSD (] Lavwvner of the pmpeny, or mY cmployms wiN wages as tM1einmle cmmpcmminn.
Pat- will do the work. and are structure is not intended or offered ansale(See. 1044. Business
ccm and Profewi(sm' Code: The Contractors License Low doer not apply to an owner or
property who builds or Improves thereon, and who does such work Watch or through
his own employees, provided that such imprnv rmass are not intended or offered far
sale. If. however, the building or improvement is sold within one year of completing, rhe
huilJe h�ilen of p 61hN M1e did ntyi M1uild of mvc Iia pas
��11 t e pm tr. am exc r coat m ng used cnnnannr i-
war dm nrnjv.:r (see. nu4. Baanterr a 1 rrofe,xi, : ,ae:Yrne camnmmrr Li-
re Law duct not apply m un owner of pmpenY won Hoods nr iinpmvcr Incrmm, nota QTY.
who commas for such pmjecu with a contraction') li eowd pursuant to the Cormclut's
License Law,
0 I am c.cmm undcr S�. B & P C for this rerom
I.LFC71 RIC PERMIT FEE
PI.RMIT ISSUANCE
APPIJANCHS - RLSIDEN'I'[A],
PANELS
UP TO 200 AMPS
SIGNS ELEC I RICAL
SPECIAL CIRCUI Old ISC.
'1'IEbIP. METIER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWI TCHI:S - FIXTURILS
NIEW RESIDENT [AL 13LECTR
�Owncr•,,"
ill W( Our, vad,of A' NDECL follonION
1 hewny affirm under, pcnahy of prjury one of Nc Gdnwing declarations:
1 have and will maintain Section
37 re of COnwm mCcdknsur the Worker's ce of th-
saion, as provided for by Scninn 3100 of the hlxm Carc, for the perfnrmanm Of the
work fill which this permit is issued.
1 have; I w111 maintain Workers Campe.ocamo Inamnnce, art required by Section
31(X1 oftha Ldso Cade, for the permmllancc of the work far which this permit In i ... ed.
My Worker's Compensation Insurance currier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAHON INSURANCE
(1'hixseninn need nut be complcnn dthe pemtit is fnzn a hnmdtwl dollars (SISP
or le".)
I employ
any that in in anyIwrforancr� manner
of the work for which this the W is issued.) shall
not employ any person in any manner m as m become mbjm m the N'orken' COmpem
Z saiun LO—of California Date
0 Applicant t
h NOI CH 10 APPLICAMI': if. after making this Certificate al Exemption, You should
F face, vuhjcct to he Worker's Compensation mo sion—I In LnMa Code, you must
funM1with comply with such Puni,hm,,u his permit shall Be deeneduevoked,
CONSTRisCr10NLIENDINGAGENCY
L6O 1 or w1urfnt,that
period
isaconstruction Ses,30lending agency for the performance of
H Le work for wnleM1 Nix punnit is I,rsveJ (Sec, 1091. Co. Cd
Nunn
O U
Lenders Address
t Lender's Address
a I certify that 1 have read this city
and
and site that Inc salve information is
UN conn,Iagree ccomply with all cityand mproty otativem Of and sate lawsrelatingupon
ge QTY.
U',� maiming construction, and hereby amhnri.e rerresmtativeaanmsdtymemer upon me
1-7
above-mentioned property for mspcalon Pu-Ecocs.
We) agree to %me, Indemnity and keep harmless rhe COY of Cape nn against
liabilities. lud,orm s, costs and expenses which may in any way acerae against said City
in consequence of the granting of this usual.
APPLICANT UNDERS"ITA NOS AND WILL COMPLY N'ITH ALL NON -POINT
TRCIi REGULATION
rY 12 ___„.)_ i nfhgll41R
V HAZARDOUS MATERIALS DISCu19Dau
Will the applicant or future building acupant store or handle M1aufdous unhand
as defined by the Cupertino Municipal Care, Chapter 9. 12. and the Health and Safety
Code. Scot 25532(a) t
C Yes 0 N
Will me applicant or foram building mcupam use equipment or device, which
emit humfdous air cockntinams as defined by he Bay Area Air Quality Management
Dot ict^
DYcr C] No
I have read the haranloos mownalx requirements undcr Chapter 6,95 of me Cali-
fornia IIea1N & Safety Cotte, Sections 25505, 25533 and 25531. I understand Nm if the
building &v,% not currently have a tenant that it is my texponobilay to notify Nc accupam
Of the requircmern which must h met pnono issuance of a Cenificnofi:`ag ib0
PLUM H I NG PERM I'I'
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WADER (EA)
BACK FLOW PROIIECf DEV ICI:
DRAINS- FLOOR. ROOF. AREA. COND.
FIXTURES - PER TRAP
GAS -EA, SYS'IEM-1 INC.4OIJ'U.IETS
GAS'- EA. SYSISIIM-OVER 4 BA)
CREASEIINDUSTRL WASTE INTERCEPTOR
CREASE TRAP
SEWER - SANITARY -STORM EA. 200 FT
WATER HEATER W/VENVELECTR
WATER SYSTEM?BEATING
WATER SERVICE
NEW RESTDENI IAL PLM#. SQ, ET.
MECHANICAL PERMIT
FERMI r ISSUANCIE
ALTER OR ADD TO MECH.
AIR I IANDLING UNIT (TO I Ih000 CFM)
AIR HANDLING UNIT (OVER I0k000 CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO hall BTU(
HEATING UNIT (OVER IIXh(XI0 BTU)
VENTILATION RAN (SINGLE RUSH))
BOILER -COME' GHP OR 100.000 BTU)
BOILER - COM(' (OVER I01,(XX113'FU)
AIR CONDE I ]ONE R
NEW RESIDENTIAL MECIL SQ. IT.
OFFICE
JOB DESCRIPTION
gla0 a5
PERMIT NO.
O KITCHEN REMODEL
El ADDITION
N I'IABI'Nfl.
OMUL'I'I-UNITE
APPI.ICAI'10nsSUI{MI'I'I'A
MODIPICA'HON
L^V f— C?(
SIC
CONTROL#
E] SWIMMING POOLS
0 BATA RHMODFUREPAIR
0 DEMOL11ION
BUILDING PERMIT INFO
HE �
GL PLUMB MEi❑CI
pi
-J
JOB DESCRIPTION
RESIDENTIAL
O SLOWL
O KITCHEN REMODEL
El ADDITION
❑ PLUMBING RE PIPH
OMUL'I'I-UNITE
OSTRUCRUEAI,
MODIPICA'HON
O INTERIOR
O CHIMNEY REPAIR
IMPROVFME:NT
E] SWIMMING POOLS
0 BATA RHMODFUREPAIR
0 DEMOL11ION
D OTIIHR
COMMERCIAL,
ONEWBLDG/ADDITION
ODEMOIJ1ION
El TENANT
01t00DSERVICIE
IMPROVEMENT
O OTHER
SQ, 1717. FLOOR ARBA
FEE
VALUAI
3/amo
BUILDING DIVISION FEES
IT ANCI HECK IEEE
ENERGY FLEE
GRAVING PER
SOILS FTI:
PAID
Dam Receipt #
___ TOTAL:
T UILDING I LE\ I I 11
FEE SEISMIC FEE y
13LE ' C'EE
PLUMBING FETE
r MECHANICAL FEE
�CONSIRUCrIONTA,
HOUSING MITIGATION PER.
PAID
Date Reeeipr#
TOTAL:
ISSUANCE DATE
, - Qji
—,�
ISSUIED13Y: S( U�—