C 0428APPLICANT TO FILL IN INFORMATION WITHIN RED
DIVISION APPLICATION/PF.RMIT
CONTACT:
"'Ll tD LUN I RAU1 OR S DECLARATION
1 hereby at] rm train I mr, licensed w d p111,111mus of Chapter 9 twat Retain,
�02 with Set 70001 of Dl T fthe Busi .a 1Professions -Code and my l'censeis
ly° in fallf d
ODU Liao l.iu# a.l- r���
yaw Da1c Contra 1
ARCHITECTS DECLARATION „.
Oz�^ tmld,ntand my Plion„hall he.,ad.,,, pmNiamar,nds
F -{L Licensed Pal 'e..imal ,
Yb J OWNER BUILDER DECLARAI-ION _
a I herchy affirm that l aproxxodirripe firmin the Contractor's License'L- for the
° 4 U following Station 7031,5 R' .. and Pramessional Code Any city at county
a` which permits a
co portrait to 't Mlle improve, d E.M1repair'anY sat e(or
- �C)� priori I m ,also aures the applicantfor such permit II gledst.bnenl
that be is licensed pursuant n the provisions or the Contractors License Law (Chapter 9
❑° (commencingwish Seddon 701 of Division 3ofthe Holmes, .nd Professions Ccee) or
t1, pi � w' that he is exempt themrnim and the basis for the alleged oxemrtinn. Any violation of
�.. m Section 7011.5 by any applicant fora permit subjects tae applicant to h civil penalty Of
�> y not more (Iran Five hundred dollars($500), '
SdQ
Fl T, us Owner or the Property, Or illy employees with wages as their sole compensation.
F will do the work and the structure is not intended or offered for wle(SeO. 7094,Busineas
( w m and Professions Code: 'I'lie Container's License Law does not apply In an owner Of
property who milds Or improves ihereolS, and woo does such work lar,..If Or Intoug[l
his own employees, provided that such improvements are not intended or offered for
sale. IL however, the building ar improvemmilt is sold within ono year of completion, the
stbtlderWill have the burden provingfthth din tb II p f p
, o"el
❑ ],,is owner of the proP TY am ascaloorvely contracting will,I' 1 contortions t
construct the pre exl (See, 7044 Business and Professions C e ) The Contractor's Li
-
came Law allies not apply to an owner Of portant Who hours p e. thenum and
who contracts for inch Projects -dlacontn ( r(s) licensed pummunt to(he Guarantors
Livense Law. -
❑IamCxemplunderSe ,B& P C far this reasm
Owner. Date
WORKER'S COMPENSATION DECLARATION
1lately afrtrm ewer Jamb, of penury nae Of the following deelsoun e
❑ I have and wiPomaded of Cenificre of Consent o self-insurefor Workers Compen-
s.tion, as pervlded far by Section 3700 of the Labor Code, for the perfnnnance of the
rr
kfwhichth permit Ye
ave
l maintain
orkers
Section
0 arm, lah ICde, ll' Ihe performanceCrth Insurance,
kfrti htlplaired p�permty iis.sueJ
crrWer:k GL InI l�nn Alyie is i nlnlb
1 Pdcy Nn.[L 4,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAf10N INSURANCE
(This smtion need not bo complem l ifthepermit idol oat hundred dollars (S 10)
or tell)
I certify that in the performance of the work for which this Permit visited, I shall
not cmpley any person m any mane'er, t Ibject t. dm Workers' Contp,n-
z notion Laws Cnliroryla. Dat• 7T f
7� Q
Applicant. /A
❑ NOTICL TO APPLICANT: If, shellacking this Certifenm Mri,ma ion, you should
become su died IC he Walkers Comp ... all nn provisions of the Lrvbor Gid,, you mtut
f cto-ith comply with such provision or, this permit,,ball be decm,d cornice.
Q
'a z CONSTRUCTIONLFNDINGAGBNCY
I hereby affirm that
Per.11ri isaea (Sea 30 lending agency for performance of
0 Le walk far whica lois permdis issues (SeC.3097, Civ. Cr
U Lender's Name
W LenderAdd....
� Iy 1 really o co 1 have moa this y and
n earn and vine ces th t nfarmvtia is
-ti Z CO) mace( Ivgremcn, and xprelty (.ryahanpmy Ord nvmcvand :I t I lar go,
Ux� budangeed.nudoldrJforinsauthorproposeCaafvesofthsClytoCn(eruonlac
.have- (We) move
prnpeny, for inspection keep It.
(We) agroe s, save, aocEnt and keep harmless the City of Cupertino again,,(
liabilities,juagmema, cost ndexpenses which may in any way mcbrnC agaimLsaiA City
imm�SCg11CI1CC IIhe ting fS A permit. '
APPLICANT a' "a
'TA ! JS A �ID WILL. MPLY 'LTH ALL NON-rO1NT
SOURCP tt! U IO
Signat of pplica ontmivor 'pate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bailding Oceapean face or handle hveallons mama.]
as defined! by Ned C.penin,Municipal Code, Chapter 9.12, .ad the health and Safety
Code, Section 25532(m? -
❑ Yes o VNO
`b Will the applicant or future building returnad use edryipment of devices which
mit retention, air nomaddr an, as defined by the Be, Area Air Quality Menag,ment
�- .'District? ,.
❑Yes VNO ,
Ih a Id n.M meallma m t' drCnrlel9.1col Cli-
[OmiaHallh&S qC t .5;2553 d25534.i understand that if the
buildia,d t t't to sr sbiliryt ."Of, theocci pant
f the ears 0Amu,, tp nw Cann �pgn
cup.
USE BALL POINT PEN ONLY
BUILDING. ELECTRICAL PERMIT NO./l;
. PLUMBING-MRCHANICAI.
.f q�10 / 2 OI
BUILDING PROJECT IDENTIFICATION I O000� 1
TEMB METER OR P0/_ RISE •.
- --
PL'ANCHECKFEE
ii//_/
CONTRACTOR'S NAME: LICNO'.
F S
NIC
'.. ❑
SWIMMING/Ml, ELEC FRIC
CON'UROL#
ADDRESS:?qilo Np-TIc]�- l.. �U
�• ys
. ❑ Consultant Fees Paid by Applicant (Initial)
•';' BUILDING PERMIT INFO '
BLDG ” ELECT
PLUMB MECH
QTY.; Fill 4i LLECTI2IG PERMIT .', FEE;,
-
JOB DESCRIPTION
RESIDENTIAL' -
❑SFDWL ❑ KITCHEN REMODEL.
❑ADDITION El PLUMBING RE -PIPE .
❑MULTI -UNIT OSURUCFURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT❑SWIMMING POOLSPS ❑ RFMODEIJRE'AIR []DEMOLfHON
OTjMO. G} TR �2.UIT/MISC. coirP—r
PERMIT ISSUANCE _ -
APPLIANCES -RESIDENTIAL.
PS
-
*PANELS
RICAL
1-rV - VAIAAf10N
B
1
TEMB METER OR P0/_ RISE •.
- --
PL'ANCHECKFEE
COMMERCIAL:
EJ NEW BLDG/ADDITION
❑'TENANT
IMPROVEMENT
❑ OTHER
- -
❑DEMOLITION .'
FOOD SERVICE
•
POWER DEVICP..
SWIMMING/Ml, ELEC FRIC
OUTIL-SWHCHES-FIXTURES
NE E.SIDEN'UALELECTR 'SQ FI'.
PAID
Date Ruc,iplI ,
NEW RESIDENTIAL PLMH. SQ. IT.
AIJER OR ADD TO MECH.
PhUMBING FF.F.
.FILFLOORARF.A
D Q �
JUL 1 3 •�99
$/SQ. [or. .
MECHANICAL PEC
• rLUME1NCPFRMiTi"' ;;N e'
PERM]I ISSUANCE? -
ALTER-DRAIN&VENT -WATER(EA)
-
1-rV - VAIAAf10N
B
1
BACK ROW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
-
STORIES
OCC. CNOUP
TYPE CONSTRUCTION
APN
'
FIXTURES PER 'I'RAP •
GAS FA SYSTEM-] INC. 4 OUTLETS
GAS LA. SYSTEMOVF.R 4(DA)
GRF.ASEANDUSTRI. WASTE. IN IERCF.I' I Olt
GREASE TRAP
- --
PL'ANCHECKFEE
SEWER -SANITARY -STORM EA. 201 FT,
ENERGY PBB
GRADING THE
WATEIL HEATER WNHNT/ELECTR O
_
WATER SYSTF,MT REATING
SOILS FEE •'
WATER SERVICE
PAID
Date Ruc,iplI ,
NEW RESIDENTIAL PLMH. SQ. IT.
TOTAL
TOTAL.
TOTAL
BUILDING FREMECHAMCAL
PERMIT, i •(' FEE ;
i 1..
SEISMIC I7LE
PERMIT' ISSUANCE
ELECT RIC FEE
AIJER OR ADD TO MECH.
PhUMBING FF.F.
AIRIIANDLING UNIT(TO I0,000CFM)
MECHANICAL PEC
1
AIR HANDLING UNIT (OVER 101000 CPM)
CONSTRUCTIONTAX
-
EXHAUST HOOD (WMUCP)
HOUSING MITIGATION FEE
HEATING UNIT (TO 1001000 B U) .
HEATING UNIT(OVER HOLD( 'Il
PAI
_
emiFl Of
'
VENTILATION FAN (SO .FRESH)
BOILER -COMPO OR100,000 RTU)
TOIAL
BOILER -CO-
(OVER 100,000 13
AIR CO TIONF.R s
UANCE DATE
(170,Q
No RESIDENTIAL MF.CiI: SQ. Fr.
OFFICE -