S 1035APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO ' . - BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION -
PERMIT NG.1035
BUILDING ADDRESS - ( /1/� ,S� / fJ�o�
&`2ek MM CJI Q `
#D0 S'�e/fc��S
SANITARY NO.
APPLICATION SUBMITTAL DATE
61'2 q
NAMEIe119
O V R(J{/' H Y M•„",��L/r/�l PHONE:
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57�Y � /� %/1 /�
CON fkA �(JRiV AW?rn/,off .N,yI{i�,,.x 3`6 668
JY •HAAm-fod
NIC
❑
CON TR()I.N
ARCHITECT/ENGINEER: LIC NO:
I'
`164 AY(. JIX`ET
R G G A
CONTACT: PHONE:
'
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG FLE I' PLUMB MUCH
❑
LICENSED CONTRACTORS DECLARATION
• I hereby a1Ble
rm that I am Measled under provision, of Chapter 9 (commencing
wpb Section 7(KKll of Uivision3nf the Rosiness and Pro(assion, Coda vnd my license isPERMIT
in fall have and ellen,
License Class "Lic.k
Dale Contractor
QTY , .' ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL•
❑SFDWL ❑ KITCHEN REMODEL
[_1 ADDITION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
ERIOR El CHIMNEY RI?PAIR
PROVEMENT SWIMMING POOLS
fr11 TH REMODEUREPA IR El DEMOLITION
❑ OTH17R
ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
1 understand my plaro,lml) he used ox public records
PANELS
I1PT021HIAMPS
Licensed Professional
OWNERBUILDERDECLARATION
1 hereby off nn that I am exempt fmm the Con...f or, License Law fur the
following reason. (Section 7031.5. Business and Professions Cafe: Any oily nr county
which requires a permit In wnstmct, alma Improve, demolish, m v,m, any proame
prier to its issuance, alsomquires theapplicam for such permit In file a,lgned,ancoem
,hut he is Batman pressure to the provisions of theCi mraam's License Law (Chaffer 9
(commencing with Section 711(10) of Division 3 ofthe Business and Prnfessians Code) or
that he is exempt Iherefrnm and the basis far the alloged exemption. Any violation of
Section 70315 by any tipplicam for. permit subjects the appliasnt to a civil penalty of
m 4 more than f ve hundred della,, (SAA)).
❑1, axownendthe pmpemy, or my enttiloyacs with wages ns theirsule wmF;n,minn,
will dothework,nndthemmetme is not mended mounted for sale(See."1044, Business
and Professions Code: The Contractors License Law tinea sol app1Y m an ewna of
property who builds or improves thereon, and who does such work himself or through
his own anployeos, Provided that such improvements are not intended or offered ter
sale.If, however. the building or improvement is sold within one year ofcompletinn.the
owner -builder will have the harden of proving ilial he did not build or improve for pur-
piae.l'atle).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors m
consumer the project (See.7044, Business and Professions CdcH The Contractor's Li-
cense Law does not apply to an owner ofproperty who builds or improves thereon. and
whownbae,for..chprojects war. contract ... F) licensed Dammam In the Conrtacmr's
License law.
❑ 1 ant exempt under Site . B & P C for this reason
201-IMOAMPS
OVER IfNHtAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑FOOD SERVICE:
IMPROVEMENT'
❑OTHER
POWER DEVICES 14,ANT
WIMMING POOL. ELECTRIC
_
WTLBTS -SWITCHES-FIXTURES
NI?W RESIDENTIAL ELECTR SQ FT.
'
SQ. FT. FLOOR AREA S/SQ. FT.
�1 p
P p I E)
$ �4�^ �
2✓ I
rl
11vV
yW
TOTAL-
QTY. PLUMBING QeAl FEE.
PERMIT ISSUANCE -
ACIER - DRAIN & VENT - WATER (EA)kyplfU�T�ON
Owner Dare
WORKER'S COM PENSATION UE Ce following
I hereby affirm under penalty of perjury one of the following dedk r s C s:
`❑ Iheve and will maintain a Certificate ofConsenl loself-insure fur Worker's Compen-
sation, as provided for by Section 37M of the Lahm Code. for the performance of the
work for which this penult Is issued
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofthe Labor Code,fortheperfolummool'Ihewofk l'cow�hich i�is�wrmn is ice J.
My Work-iartierond PoliW,p ire;] 7Vf1A.
Carries Policy No..
CERTIFICATE Op EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted ifthepermirisforonehnndredslolla V I0i
or less.)
I certify that in the performance ofthe work forwhich this permit is issued, l shall
nyneto r so as to become subject the Worker CmrEm-
solemploy any person in aman
satins Law, of California. Dam
ApplicantGRADING
BACK FLOW PROTECT. DEVICE.
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FIX'1'U RNS - PIR 'IRAP
GAS-F.A. SYSTEM -I INC.40
OCCGROUP
APN
OAS-EA.SYSTEM(lVER4(RA)
GREASIVINDUSTRL WASTE INTERCEPTOR-
BUILDING UIVI9ION pE.R
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
FEF.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Limon Code. you must
forthwith comply withauch provisions or this permit shall iso deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the workfur which this permit is issued (See 3097, Civ. C.)
Lenders Name
WATER SYSTEMGREATING
WATER SERVICE
SOILS PEE
PAID
D. RocaiptN
NEW RESIDENTIAL PLMD SQ. PC
TOTAL:
Lenders Address
TOTAL,
BUILDING PEE
I certify that 1 have read this application and state that the above automation in
sorted. I agree to comply with all city and county ordinances and sate laws relating m
building anemrctlon, and hereby authorize n pfesemerives of this city in enter upon the
shove -mentioned property for inspection particles.
(We) agree to save indemnify and keep harmless the City of Cupertino against
liabilities,judgmenls, costs and expenses which may in any way acerme gainst said City'
in ouseyuen't granting of this permit.
APPLIC 'Pt "RSTANDS IL C0 LY�WIII ALL NON -POINT
SOUfj TI NS, n /P✓V'
l//'y/t
..
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
SEISMIC FEE
ELECTRIC P > r
PLUMBING .E
AIRHANDLING UNIT(TO 1O,000CFM)
MECHANl
ALPEE
AIR HANDIANGUMT(OVER IO,WOCFM)
CONSTR
,HON TAX
Iicam, car Date
H AR OUS MATERIALS DISCLOSURE
pplic„orf vre huliding rccup.m emrenr hundlehmardnm mulerial
Signat�ep
as def Cu rlino nicip.l Calle, Chapter 9.12, and the Health and Safety
Code,532 .)1
0 N
Will the applicant or future building nwupanl use equipment or devices which
hazardous air nnants as defined by the Bay Area Air Quality Management
emit hazardwami
District? Vex ❑ No
I have read the hazardnax materials requirements under Chapter .695 of the Cul-
Form. Health & Safely Cade, Sections 25505, 25533 and 25534. 1 understand trial if the
building urea not currently have a rancor, that f is my responsibility to notify, he ..,air[
of the ragabemem, which most be met prim to ieme nce of a Cenificale of Lee .... cy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIG ONFEE
HEATING IINITGrD 00,11110 BTU)
HHATINGUNIT(OVER100,0fI11 RTU)
PAID
Data R11”# '
VENTILATION FAN (SINGER RESID)
BOILER -COMP (3HPOR 00,000BTU)
TOTAL
BOILER -COMP (OVER 103,000 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUEDBY '.
NEW BESIDE N'I IAL MHCH. SQ. FT.
gent - Date
Owner or authorized asjzw
TOT
OFFICE