S 0108APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB.DING- ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTIDENTICAI.
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BUILDING ADDRESS:
SANITARY NO,
APPLICA'T'ION SUBMITTAL DATE
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I 13UILDINC PIiRMIT INFO
e FL PLUMB M
-I sip
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under previsions of Chapter 9 (commencing
with Secmlon lUfX)3 nfDlvisinn3nf the Bueineva trod is Code, Wll, licemeis
in full force and effect.
License Class Lic'K
Doe Contractor
QTY
- ELECTRIC PERMIT
.FEE
JOB DESCRIPTION
RFSIDFNTIAL:
❑SFDWU [I KITCHEN REMODEL.
❑ADDITION ❑PLUMPING RE -PIPE
❑MULTLUNIT C:1 STRUCTURAL
MODIFICATION
C3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C]SWIMMINGPOOI.S
❑BATH REM EIIREPAIR C1 DEMOLITION
w A
❑ OCHER M— --n
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL
ARCHITECTS DECLARATION
l umlerd my pions shall he asedas public records
tan
PANELS
UPT021X.. Ahfl'S
Licensed Professional
OWNER-HUILDER DECLARATION
I herchy affirm that I am exempt from the Contractor's License Law for the
foliating Henson. Pleetion 103 L5. Business and Professions C de: An 't t
g y city or county
which it,i ceue.,is.mcone, mucaltur,improve.demolish. nren sigany ntennaI
PH.". t he lhovisiosofoac Itenta aw(Chater,
he is licensed pursuant lathe proviainnsofthe Cnmruaors License Lew (Chapter,
(commencing with Section 7Wlpnf Division 3o(the Business and Professions Culd0a,
that he is exempt therefrom and the busie for the alleged exemption. Any violation of
Section 9W L5 by any applicant for a permit subjects the applicant In a civil penalty of
team than five hundred dollars(S500L
❑I, as owner of the property, or my employees with wages us their sale compensation,
will do the work. and the structure is not intended meta red for sale (Sec. ]144,1{usinesy
end Professions Cole: The Contractors License Law does not apply to um an t/
property whit builds or Improves thereon, and who dues such work himself or thmugir
his own employees, provided that such improvements are not intended of offered for
ade. If, howcvcrshc hathing or improvement is sold within one year ofrompleticutdn
owneobuilder will have the burden of proving that he did not build or improve Inr pur-
pose of sale.).
1, as ow r of the propcny, am exclusively contracting with Icensed cataract v to
retrvet the project (Sec. 1044, Business end Professions Code:) That Cantmena's la.
verse Law does not apply loanowner property will) builds or improves thereon, mil
who contracts for such protects with a comrenm(s) licenad pursuant to the Committees
Liwnsc Low.
LJ l am exempt maker Sec. , e & P C for this reason
201- 1000AMPS
OVER load AMT'S
SIGNS ELECTRICAL AJ
SI'IiCIAh CIRCIII'/
��a�.
TIiMI'. MIiTER( .E S.
M�IviH1C/C�PA.
CO
"
3 (-,/ADDITION DEMOLITION
A�1' Uut,t L,t OOD SERVICE
,IMP -- rI �(
IMPROVIiMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
IfTL[TS— SWI'I'CHLS— XTUNIS
N17W RESIDENTIAL ELEG'IR SQ PI'.
SQ. FI'. FLUOR A PA
/1 9 QO �
G (�(`
ESQ. FTr
's
r
QTY.
-
PLUMBING PERMIT
( FEE
PI7RMIT ISSUANCE
Owner DIma
ALTER — DRAIN & VENT— WATI7R (IAA)
BACK FLOW I'ROFfiCT. DEVICE DEVICE
VALUATION
q 2 q L G
WORKER'S COMPENSATION DECLARATION
I hereby
dwill around a rally it ofCouoncnl' the imam ingdevlkeetioo
❑..have and will maintains Cion 370eof he Lab rCode, for the WOtkers Compel,
svtinn, es provided for by Section 1'IRd of the Labor Code, for the perfnrmanw of the
work for which this permit is isued.
I have and will maintain Worker's Compensation Insurance, as requited by Sedinn
3100 ofthe Luber Code, lot the perfonnamceof the work for which this permit is issuol,
My Workers Compensation Insurance currier and Policy number ore:
Carrier . Policy Na.:
CURTIFICATI: OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
is ction need not beconpined if thelcnnit is fanme hundred dollars ($..fX)
(Th se
or less)
.. ccnify that in the pennnnance of the work l'or whichthispermitisissued,lshall
not employ any person in any manner so as mm become subject to the Workers' Compete
ason Laws of Califomia Date
m
-
DRAINS — FLOOR. POOP. AREA, COND.
STORIES
'I'YI'li CONSTRUCTION
ITXTURIN — PER TRAP
GAS — EA. SYS'I EM -1 INC. 4 OUThETS
OCC. GROUP
AI'N
GAS — EA. SYSTEM OVER 4 (EA)
GRF.ASI %INDUSTR.., WASTE INTERCEPTOR
BUILDING DIV ION PIiF.S
GREASE TPA..',
PLANCIiI!CK FEE
d �
SIiWER— SANITARY— STORMI3A.2(X)FF.
ENERGY FEB
WATER HEADER W /VEN'DE FOD<
GRADING FEE
Applicant
NOTICE T'O APPLICANT: If, Mier making this Ceniricate of Exemptible, you should
subjecrmthe Workers Compensation provisionsof the labor Code, you must
forthwith comply with such pmvision.x arthia permit a hail he deemed revoked,
CONSTRUCTION LENDING AGENCY
(hereby affirm that there iaacnnewctlnn lending agency for theperformm�m of
the work for which this permit is issued (Sec. 3097, Civ. CT
Lender's Name
Lenders Address
WATER SYSTHMaREATING
WATER SERVICE
SOILS PEE
PAID
)u kemipta
NEW RESIDENTIAL PLMtl. SQ, FT.
'
TOTAL:
.I.
-
BUILDING FEE
ccnify that I have road this aTiNici Lion and state thus the Mice information is
correct. I agree mcomply with all city and county ordinances and state laws relating to
building comumetion, and hereby adhoriu representatives ofthisciry memeruper the
above - mentioned pro any for insp elion purposcs'
(We) agree to save. indemnify and keep hamJeas by of Cupertino against
llabllitias,judgments, costs anti c ve whi ry 'a yacrooluuinslsaid City
ansequence of the grvmin this
APPLICANTU DERST A II 1 LY WITH ALL NON-POINT
SOURGULA 'I(
G4a� 4
`
Q Y.
MECHANICAL PERMIT'
FEE
SEISMIC FEE
PIiRMI'1' ISSUANCE
ELECT PI 3
e
AFTER (1R AIID TO MECII.
PLUMBING IiE
AIR HANDLING UNIT ('1010,000CFM)
MECHANIC LFF.E
AIR HANDLING UNIT (OVER10,(pOChAD
CONSTRUCIU TAX
Sign awre snot or Dar
HAZARDOUS MATERIALS DISCLOSURE
Wi plicate or future Wilding occupant store orhandiehamNOus material
us early a Cupertino Municipal Code, Chapter 9.12, and the Health anti Safety
Coe. Section 25532(x)'1
El yet 71 No
t Will the applicant or future building occupant use equipment or devices which
t hmultous air contaminants as defied by the Bay Area Air Quality Management
Dionet?
❑Yes ❑No
Ihavo revel the hararskas macrt rcgqoiiemcros nailer Chapter 6.95 of the Coln
Limit Heahh & Safety Codes Scedttions�95(L{,'L5533 and 25534. 1 unActxtnnJ that if the
building Arcs out curr��ppOY hav9e tcnan0 th6s�is my rtspansibilimy m notify ale recuryit
ofd�rgd cn> 6'I(h mus, caet.�ripr '1,issmmmofaC licat to to
✓ .A
�
EXHAUST HOOD(W /DUCT)
HOUSING MIT FIGS] FE
HEATING UNIT (To 100.00 BI
HEAPING UNI'i' (OVER 100.000 It TO)
..'AID
-
VIiNTILATIONFAN(SINCLERI ?SIU)
pore Receipt
BOILER —COMP (JHP OR IIXI,IXX) B'IVI
I {OILER —COMP LOVER 100.t11p tlTU)
AIR CONDITIONER
ISSUANCIi DATE
ISSUED BY 71110V
NEW RESIDENTIAL. MECH. SQ. IT.
L.
0
Owner mamhorimd ug 1 n)T
V" OFFICE
lwkNT,:;
Elf M
14
le:
L
Noa 59
THIS IS 0 CERTIFY fhaf th"61"i
ng or s
Pfidn of building
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..... ankiro),
. only)
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L
N ............
E're'c+b d6k L 0
'13 'Ock"No'
Addition c. '
p U F 4
. ......
Architect James W, -F Zone
... ..
......................
...........
..........
C t
on rac,
..................... c'.
'B u 1- Id 1 n' T" P'err m` WN o 0511 '-'PI'an,'No,;
a e,enjnsped-te
an d illi" e follbwll 6f,66
-th 44916f authorized
Max . A o w pp,4 'f+ O,CCUP.ANCI S
o6
� pe,rs.
asement e-j
. . . - - - - - - -
7. . . ... . . . . . . . . . . . .
2nd floor. 5011 .............
-'.7.77
3rd; floor ............... ..
..... ..... ..........
........ ..
..........
........... --------
..... ................ .
........... ........
4th ..........
...............
Add floors 6 ........
d
as s-sal
: ece.l ..... .. ..... �m
..........
................ ..............
........... ......... ...... ......
.b Roof.
12 IT & #4 (4..,:
.......... 7-7
...........
Cit of CUPE Feb 9r 13.
y
I J 19 .........
X.. .
This certificate 6e' pos e anici
must peirmanently"ma, f;
in aine in, 6%; o,
Close 40 66� of,fh
�Llor'Sft
��Ilaeri ' ra 6, building uc Lure referred to'a