S 07900.
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- ELECTRICAL PE 611'1'NO,
♦ BUILDING DIVISION APPLICATION/PERMIT __- PLUMRING-MECHANICA], 0790
BUILDING ADDR
l9,A0
OWNER'S NAME:
1,V..
CI ITI[CDENG
lCONTACT:
yre
NAME:
I.I N 16d J4 1217E
&50I E:1Consultant Fees Paid by Applicant (Initial)
rcS� I
-1Z
I hueby affirm .fiat I um liceasscd under provisions of Chvptcr 9 (nmmnmoncing
nx, with 5«cion tlg0)nf DivisinnJ Done Ousinexs and lhnfessiotn Cale, Tend mY license is
in me force tad off 3 �r' o
aUU License Clash -•4 S LieN 9 /ew
n Z yI pate—-�r2,3•Er1— Commdrn S
6' 1,
ARCHITIRCrs
ate UIiCLARATION
IunJersmheated.,
nd my plans shall c hseA as public ncnrrs
Z-0
3 W Lacnsed Professional
OWNER -BUILDER DECLARATION
x 6oot I hereby affirm shat 1 am exempt from the Commorms's License Law for the
00.0F�followingfeoW..(Section 70)1.5,Basine.,, and P..basiom Cale: Any rayer county
LL ON which requires a permit to om. , ala,. improve, demolish, or repair any n penal
st pdnnoios issuance, also requiresohc upplicam for such permit In file asigneJ stateroom
ythat he is licereed putsaont to the provisions of the Comfort,' 11, cense Low (ChvparJ
pC(commencing with Section 70010) of Division B of the Nosiness and Prof dons Code)or
yy that he is exempt therefrom trod the basis for the alleged ammume. Any violation of
Section 7131.5 by any applicant fora permit Tobacco, the applicant to a civil penalty of
^Zy at some than five hundred dollars(S5W).
p
C1-] 1, as owner of the property, or my employees with wages xs.heir ode coupe nsation.
fC� will Jotho work, and thcmrucmre isnot pleaded orn11 rmd for onto (Ser. 7044, Business
W i and Professions Code: The Connanar's License Law does not apply to an owner of
property who builds or improves thereon, anti who does such work himself or through
his own employees, provided that such Improvematns are non intended or otfamed tar
sale. If, however, she building or improvement is sold within one year of completion, the
owner -builder will have the barren of proving that he did not hold nr improve for par-
pos.
oo-pas. of sale.).
❑ 1, as owner of the popert%ata exclusively contracting with licensd contractors to
construct the project (Sec 70,14, Business Tend Pmfcsxlons Code:) The Comrudnr's Lli-
nse Law does not apply to an owner of problem who hullAv it,improves thereon, and QTY,
who contracts for such projects with a caricaturist license) pursuant to the Contrecto's
License Law. .
I vat exempt under Sm. ,BFtPCfor phis reason
ELECTRIC PERMIT FEE
PERMIT' ISSUANCE
APPLIANCES - RF_SIDIPU AL
PANNI S
UP'1'0200AMPS
201-1000AMIIS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'I'/MISC.
TEh1It METER OR POLE INS,
POWER DEVICES
SWIMMING 1.001, ELECTRIC
OU'ILI?TS - SWITCHES - fl%TURES
NEW RESIDENTIAL ELECI R SQ IT.
owner Date
WORKER'S C(IMPEN SATION DECLARATION
1 hereby am. under penalty of perjury one of the following decltaminns:
[have and will maintain v Certificate of Consent to scl6insure for Workers Compete
mann. as provided for by Section 37(M1 of the Labor Code, for the pe formuree of the
work for which this permit is issued
1 have and will mninain Workers Comnlwnsation Insurance, os required by Section
3700 of the Labor Code, for the performance of the work for which his permit is issued.
My Worker's Cnmpensn' Economic. tamer and Pal icy nulpheryaA
Curri¢�D— PION Na. f 606 S
C ;RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section neednm be completed If the permit is 6r one to decddoll... (SHME)
or lea.)
ley citythatimhe frf anter Tee worn a h'c this ^^yyit i.' aou'ral
not employ troy person i man us m tont s �d Yyi ' Cnnspen
O,Z, xaoinn Laws of Celifoe
77 0 Applicant
a In NOPICE ro 1.1.1 1 'r: If, after making this Critunaam of Exnnptim, you should
F become subject m th criers Cona,m umn Provisions of the labor Calc, yon must
forthwith comply with such provisiersor Ibis permit shall he deemed mocked.
44 Q
n' CONSTRUCTION LENDING AGENCY
V Ifahereby which this there ixaconmer.Erl.lending agency for the performance of
[1. (..
the Weak for which this perms is lssuW (Sec. 3097, Civ. C.)
Q Lender's Name
[31 Isnde/I Address
G 1 agree that I have mad thirty an coup Tend state that the above information, mining is
h7
correct. lugreemcomply with all cityaod countyordinancesand stmelawsrdatingr, QTY.
V a alrovengammralproenti forinspechmiuroprescntmivice nfthiscity of rnmramon the
uhovea(We) are property forinspectionloop hs.
(We) agate o save, indemnify and keep harmless they ay of gulp nn id Ctagainst
liubilitien,judgments, eosins and expenses which nwy In any worry ummevgainst raid City
in consequence of the gmming Idspe it.
APPLICANT UND RST AN ILL C MPLY ' ALL NON -POINT
SOURCE RF UI '1
Si f Plicant/Contractor Dale
HA'LARDOUS MATERIALS DISCLOSURE
Wthe applicant or future building occupnm some or handle haumlaus mamnal
as defincol bydhe Crisman, Municipal Code, Chapter 9.12, and the Health and Sal fly
Code. Section 25532(a)?
[:1 Vic, ❑ No
PERMIT
ALTER -DRAIM VW WAIT,
BACK FLOW PROTECT. I?VJ E
DRAINS - FLOOR, ROO].ARHA. C(
FIXTURES - PER TRAP
GAS - EA. SYSTHM-I INC.4 OU JILErS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASF/INDUSTRI. WAS' 11: INTERCEPTOR
GREASE 'I'RAP
SEWER -SANITARY -STORM EA. 200 IT.
WATER BEATER WNENT/ELECTR
WA I 13 SYSIKM([ REAd INE
WATER SERVICE.
NEW RE41DEWIAL PLMIL SQ. PT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD I11 MECI I.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER MIMEO CPM)
RXI MUST HOOD (W/DUCII
BEATING UNIT (TO 100,000 BTU)
TREATING UNIT (OVER I00.00K)BTU)
VI?NTI1.Al'ION PAN (SINGLE, RESIDE
Will the applicant or future building occupant use equipment or devices which BOILER -COMP (7HP OR 100,010 BTU)
emit hromrcnux air conwminanls re defined M1y the Bny Arca Air Qnalily Management
District? BOILER- COMP(OVER I01).0001ITU)
❑Yes • ❑No
(have reasi the hmardous materials requimtrrcnts under Chapow 695 of doe Cali- AIRCONUITIONIiR
famia Health & Snfep Cale, Senions 25505, 255JJ and 255]4.1 undersmnJ chat if the NEW RESIDENTIAL MECIL SQ, ITT
hu thng dopa not curenthave a tenant Ihnt Ix nry.evpmslbility m manly the ocntpllm
of Ithe rryuimmnns whichh mou h+moo prior
o issuance of. Cmificam of (kcupanry.
Is]
PERMITINFO
PLUMY MEC
❑ ❑
JOB DESCRIPI ION
RESIDENTIAL:
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
E:1 PLUMBING RE IEPR
❑MULTI -UNIT
❑STROC7'URAI.
MODIFICATION
LJ INTERIOR
CCHIMNEY REPAIR
IMPROVEMENT
CSWIMm ING POOPS
C BA'I'II REMODI UREPAIR C DEM01.1'I'[ON
❑ OTHER
COMMERCIAL
❑ NEW BLINIADDITION [I DEMOLITION
❑THNANI' C1'OOD SERVICE
IMPROVEMENT
C OTHER n
r M
SQ. IT FLOOR AREA $/SQ. FT.
DEC 2 3 RECD
FEE I CITY Lir WtstHilNO
PLANCHUCK PER
EN1iRGY ITL!
GRADING P
SOILS Pli
PA
te
Receipt p
TOTAL:
BUILDIN I>EF.
FEE SEISMIC
ELECTRIC FEE
PLUMBING 17FF.
ME
CHANICAL FEE
CONSTRUCTION FAX
HOUSING MITIGA I ]ON Fli
PAID
Data Itcccipa N
TOTAL: (ISSUED
OFFICE