31004TO FILL IN
BUILDING DIVISION
ATION WITHIN RED LINES = USE:BALL POIN
BUIL
APPLICATION/PERMITPl.GS
IIUII.DING
c IZc:,k 1�1
• I`B CONTRACTORS NAMIi:,
1n-1• 'Irl.] %—� MAI _t..l�
•� oma- ` ,:
LICENSEDCONI'RACTOR'S DECLARATION,
I nereny afOmt that lam licen,ed tinder po,,kiomm oI Chapter 9 (rommencing
p�pZ wilh Section 7000lprf Division 3 ofthe Business and Professions Code, and my license is
H w O In fun force and erceel.
U V License Class Lic. M
y Z W Dam Conxll�venor -
ARCHITECTS DECLARATION
C
Z4—
I understand my plane shall tie used as public merits
P41" Cl Licensed Professional
PEN ONLY '
IDENTIFICATION
❑ Consultant Fees PBid by Applicant (Initial)
Q1'Y. ELECTRIC PERMIT FEE
�} PERMITISSUANCE
APPLIANUS - RISIIIENTIAL
IUPT0200AMPS
.OWNER -BUILDER DECLARATION
a 1 thereby Il m had I � cammpl finnii the CiannElo, Lfmmm Luw far the
L?y5O1U billowing amant. (SIclim, 91315 Basin.. fail Pedr,ion,C J A ycity' or County
t� a LL of costs, which requires a Permit ,, cssitenal , improve, de oh. rr repair any structure, pdama its issuance, also requires the applic tforsuch permilmElcesi,ncd smmmcni
i � that he is licensed pursusnno the provisions ofthe Cnmracmr's License Law (Chapter 9,
W_D0 (commencing with Section 7000) of Division 3 of the llusineas End Professions Code)or
1 001: that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Ice Section 7011,5 by any applicantf jurnat subjects the applicant to a civil Penalty of
F Cnot do f- hundred d ll (5500)
❑1 toovurarnfabe opm, army cropli.yee., with calla,sl I p mon
will dob k End ll a- t tintended foadI I (Sar. 7044 Basin...
.,fit P es,ions Code I fie Countraticaf License Law d t ti p,ly to an neruf
0. property who builds or improves thereon, and who does such xork himself on through
'r his own employees, provided that such improvements are not intended or offered for
ale. IL however, the building or improvement is sold within tine yamof completion, the
mauff,builder rill have the human of proving that he did not build ur improve proton,
,eve of
erton-
,eveof sale J.
rl h as owner of the prnpeny, am exclusively contracting with licensed convectors to
container the Project (See. 71,44, Business and Profession, Coda:) The Contraemr, Lb
ase Law does not apply man owner of property who hands or Improves thunco,unit QTY.
who contracts for such pr Jews with u commences) Ilcem'nl purnwnt to the Gmmrcln''s
License Law, v r •' ' -
❑Iaateabo tunder See P ,0& P C for this reason
�Owner Date
WORKER'S COMPENSATION IlEC1.ARA'1ata
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a CenificamofConsent In ardl-owre for Worker's Con tr
,rain., as provided for by Section 3700 of the Labor Code,'or the performance tip the
work for which this Perot!, 1, is wed, -
01 have and will maintain Worker's Compensation Insurance, E, rc,.i,,l by $,,titin
Goal of the Labor Code. far the herfinmunce of the work for whieluhls Permit Is issued.
My WoJ,;,j•Gpn,mn Elipn lnsurdi carrier and Policy It Lt CL Zj(
SIGNS
TEMP. METER OR POLE INSI'.
POWER DEVIC17S
SWIMMING POOL. ELECTRIC
NEW
PLUMBING PERMIT
PERMIT ISSUANCE'
ALTER - BRAIN & VENT`- WATER (EA)
BACK FLOW PROTECT. DEVICE'- .
DRAINS_ FLOOR. ROOF, AREA. COND.
FIXTURES - PER TRAP
GAS -EA. SYS,1I,M.I INC'4OU'1'LF.TS
GAS -EA. SYSTU�- OVER 4 (EA) v
PER°"1T.ND.
31004
SANITARY NO. APPLICATION SUBMIITT17ALDA9E
NIC CON'I'ROLM '
o 0�
I'"BLDG ELECT
PLUMB MECH
GREASEANDUSTRL WASTE. INTERCEPTOR
11
JOB DESCRIP'T'ION
'RESIDENTIAL' -
❑SFDWL
-
O KITCHEN REMODEL.
❑ADDITION
❑ PLUMBING RFPIPE
❑MULTLUNIT
❑STRUCTURAL
GRADING AILING PLE '
MODIFICATION
INTERIOR
EI CHIMNEY REPAIR
IMPROVEMENT
NEW RESIDENTIAL PLMH. SQ. FT.
❑ HATH REMODEUREPAIR [I DEMOLITION
❑OTHER '
Lender's Address
• . TOTAL:
-
I3U I LIIING TCC
Iearlly that I have mnlan. pplcat n andt1 (but the above- inficonationis
correct Ia,am to emnply oilh :,It ,,, ad county d d:r to la til gin
huddngconstmcuan, and hereby ammum reporEsnumlves of this city Incineration the
amme-morro met property for inspection perp news.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, its and eepenses which may in any way aarue against and City
in consequence ofthe granting ofthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S TIONS.
/S FIFS �')?_C'�
Yj eO L.
COMMERCIAL -
OMMERCIAL:❑NEW BLDG/ADDITION
E] NEW
❑DEMOLITION
JOI(ENANT
'EjFOOD SERVICE
IMPROVEMENT
i
�0,1111iR
n
MECHANICAL FEE" -
_ ..
SQ. IT. FLUOR ARIA
TOTAL: '+ • �® Q fa. R�(�
FEE >
eLl
STORM O11 F. CONSTRUCTION
.z
.' O.O
z'y
a;
l[7
U
H
O ULaushr's
i.. Val
?nit
-
CERTIFICATE 017 EXEMPTION MOM WORKERS'
. COMPENSATION INSURANCE
(This sommmneed nut hecompleted ache permit is for one hundruldollan($UEB
orlea.)
which sti t itis " red, ],hull
Ieiffy tht nth tin ceo as to become
ante ply ifC person in ynnn rata, [o necnme wunjena )h W k iCompcn
Applicant ant' fC fl nn Um - _
GREASEANDUSTRL WASTE. INTERCEPTOR
11
-
BUILDING DIVISION FEES -
GREASETRAP
PLAWHECK FEE wi /
SEWER=SANITARY-S[ORM EA. 200 VL
ENERGY RCC '
WATER HEATER R'
GRADING AILING PLE '
NOTICE TO APPLICANT`. If, after making this Cenificam of Exemption, you should
became subject to the Worker's Contaminated provisions of the Labor Cuba, you nmsl
forthwith comply with such provisions or this permit shall be deemed revoker].
.CONSONLF.NDINGAGENCY
Thereby affirm that em is is aconstruction lending agency pooh, performance of
the work for which this permit is issuud(Sec. 3097, Civ. C.)'
Name
WATER SYSTI'.M/1' [ ATINOLECT
WATER SERVICE
SOILS FEE
PAID
Data Receipta
NEW RESIDENTIAL PLMH. SQ. FT.
'
- n
'.
'TOTAL:
Lender's Address
• . TOTAL:
-
I3U I LIIING TCC
Iearlly that I have mnlan. pplcat n andt1 (but the above- inficonationis
correct Ia,am to emnply oilh :,It ,,, ad county d d:r to la til gin
huddngconstmcuan, and hereby ammum reporEsnumlves of this city Incineration the
amme-morro met property for inspection perp news.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, its and eepenses which may in any way aarue against and City
in consequence ofthe granting ofthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S TIONS.
/S FIFS �')?_C'�
Yj eO L.
QTY. MECHANICAL PERMIT FEE
SEISMIC FBI` -
PERMIT ISSUANCE
ELECTRIC FEE
ALTERORADDTOMECU
PLUMBING FEE,
AIR HANDLING UNIT (TO 10j" CFM)
n
MECHANICAL FEE" -
A I R DAN DLI NO UNIT (OVER 10,000 CFM) , �
CONS'I'RUCTIONTAX
Signature of ppllcarmac oon" Dole
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant store or handle hazardous material
as defined by the Cupertino Mlinicipal,Code, Chapter 9.12, and the Health and Safety
Cale, Seen.. 25532m):'
•0 Yes ❑ Na
f Will the appbcam or future building occupant use equipment or devices which
hazardous air contam wins itsdefined by the H ty Arca A Q I ty Mane,amm�t
Ili,. ml -
❑Yes C] No
Ronda Health & Safety Cole, Sectiones 23505, 25533 and 25534.1 to dersnand ohm if the.
build, t 0 have amnan, than it is my respnnsinilitymnotify Ne uccupam
or One qui wh mon he me, Poor 1. (if. CecniOca¢o cutancy.
-7
[ IfAUS'f 11001)(W/DUCT)
HOUSING MITIGATION PEC
HEATING UNIT OD 110,000 HrU)
,
HEATING UNIT (OVER 100,001) BTU)
PAID
DateReceiptp
VENTILATION PAN (SINGLE RESID)
BOILER-COMI! (3HP OR 100,000 BTU)
"TOTAL:
BOILER-COMPIOVRIR 10i),OlOBTU)
- .
AIR CONDITIONER,
ISSUANCE DATE
ISSUED us,
NEW RESIDENTIAL. MECH. r SQ. FT.
Owninuauoncordagent Dam
- TOTAL:
a OFFICE