00010020APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING DIVISION
2U
APPLICATIONIPERMIT
M
ACI OR'S AMC: IJCNO.
NIC ROI.
.SS q ❑ L-749
O�
❑ Consultant Fccs Paid by Applicant (Initial)
I herchy aIfina That I an licensed under mv, isluns of Cbadcr 9 (commencing
wo�7 with Section 7000) of Division 3 ofthe xusinexsand Proficoions Gde. and mylicense is
F�'-�� i11 fall force and en"',
CWF' License Class hie, p
d, a U'a Convector
ARCHITECTS DECLARATION
F non
Z I understand my plans %hall he umd a% public records
OZ—a
[-.4My) Licenmd Professional
.J
OWNER -BUILDER DECLARATION
O WOwl< 1 hcrcby affirm that I am excngn fruan the Contractor's License Law for the
d U following rens..... fSstiom ]0315, ILaeinen%unit Professions Code Any oily... c..anty
which rcvnires a prona to construct, alter. Improve, demolish, or repair any am arm
01 prior to its icwanee. also requires the applicant for such permino file a signed statement
that he is licensed mrsmnu.The provision, of the Commence, Lken.se Lw(Chapter 9
(commencing with Section ?00)of Division 3 of The Business and professions Crude)nr
a d C that he is exempt therefrom and the basis for the alleged exemption. Any violation of
W�_LL Section 7031.5 by any applicant for apermitsubjects the applicant to a civil penalty of
Nnor or than rive hundred dollar, ($5001
^ Q ❑ I, as owner or the propi or my employee, with wagesas Their sole compan,eion.
.a{E. will dothe work, and lhestructum knot intended oroffered torsele(See. 7044, Business
ty m and Professions Com: The Contractor's License Law does not apply to an owner of
property who build, or improves Thomson, and who does such work himself or Through
his own employees. provided That such improvements are not medical or offered for
sale. If, however, the building or imFmvemcnl is sold within one year of completion. The
ow crbuilder will have The harden of proving That he did not build (ir improve for put.
,, c of .IT.)
❑ 1, as owner (il'file property am exclusively contracting wish licensed emirolctnrn nr
imcnict the project (Sec.'AM4. Business and 1'rofessivm, Code.) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon. and QTY.
who mntmcts for mchnojeas with a ennttarl licensed pursuant to the Contractor's
License Law. /!/
1:1l am excatpriaY/P 5k. _.�r�� . x Xt P c f�r this
ELECTRIC PERMIT
RESIDENTIAL
PERMIT ISSUANCE
❑SITOWL.
APPLIANCES — RESIDENT 'I AL
❑ADDITION
PANELS
UPTO 200AM1'S
❑MUUI'1-UNIT
201-1001 AMPS
OVER IIXMAMPS
0INTERIOR
SIGNS ELECT RICA].
IMPROVEMENT
SPECIAL. CIRCUIT/MISC.
❑ BATH REMODEL(REPAIR ❑DEMOLITION
TEMP. METER OR POLE INST. 10
POWER UIiVICEs
SWIMMING 1'001. I31,EC'IWL
1
OUTLETS—SWITCHES—FI "' i5
NEW RISIDIiNT1AL F.LECB
SQ FT.
WORKER'S COMP ENSA'I ION DCCI.ARA'I'ION -
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have sod will maintain a Cedifica¢ ofComenuo self -insure for Worker's Campen-
,ation, as provided for by Section 3701 of the Labor Cade, fill The performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3?Of) of The Labor Cosle. for the performance of the work fur which This pcmnil is issued.
My Worker's Cnmpenuanion Nvarance namier and Policy m n k" ale:
Cavia: Pulley Nn:
CERTIFICATE OF EXEMPTION FROM WORKId S'
COMPENSATION INSURANCE
('this section need not becomplend dThe permit is for -one hundteddullooO 100)
..r less.)
1 certify that in T performance of the work for which This permit is issued, I shut[
not employ any i'ersinon in any manner so as m become subject to the Workers Cnmpery
O Z alion L:w%of' CulJorniu. Ds rte
Z O A,pnwn,
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
F ^
become subject to The Workers Compcnodom pmvi%lons of the Labor Calc, you must
{aA ? forthwith comply with such provisions or This permit shall he Jamed revoked.
n'
CONSTRUCTION
U O 1 hereby tailor that
on
That ere x convolution lending agency for man
the perforce of
W P the work Gnwhicb Ibis permit is ,ccal (Sec. NN7.61. C.)
0 L) lander', Nunn,
❑ Lenders Address
y I certify that I nave read TMs aPPlicatinn and state IM1at the above inf l tion is
,.. h correct. I agree to comply withal] city and county ordinances and slate laws relating to QTY.
U Z building conswction. and hereby authorial mpmwntadveS of this city in enter upoone
'—' above-mentioned property for inspection purposes.
(Wel ugu In Suvc, mdcnmify unit AmP M1umticss the City of Cupertino agoinm
Ila hl '1t costs and expenses which may in anY way:mcme against nail City
in conscyucncc y1/lhe graining of This permit.
n VVI tr,V,i D1iRSTANDS AND WIIATCOMPLY Wfill ALL NON-I'OIN'I'
Fdcfir��d
ature of Applicant/Comanor
Dare
IIALARDOUS MNI'FRIALS DISCLOSURE
ill t hea,pli,io nr tame hinkingnccupar, stareo, a Ifehwedousmaterial
by the Cupertino Municipal CodeChapter 9.12, send the Ilealth mW Safety
, Section 2553201?
❑Yc% ❑No
Will the applicant or future building occupant use equipment or devices which
mit hacvdnus air coinmi
unants as dcxned by the Bay Arca Air Qualify Management
Disvid?
E] Yes No
I have rc The factorial, materiels mquiremcnts under Chapter fi 95 sof the Cali
morn II,,ITh rely Cede. Sections 255115. *533 and 25534.1 ancient anal that if the
PLUMBING
PERMITISSUANCE
ALTI?R — DRAIN R VENT —WA1 17R (EA)
BACK FLOW PROTECT DEVICE
DRAINS— FLOOR. ROOF, AREA. COND.
FINTURIS—E'ER TRAP
GAS — EA. SYSTEM -I INC. 4 OUT
GAS — FA. SYS'117M OVER 4 (EAI
GREASIYINIIUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER — SANITARY — STORM EA. 200 FE
WAI'ITS II BA I 17 WNENTIFLECI'R
WATER SYSTEM/I'BEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. pT.
MECHANICAL PERMIT
PERMTr ISSUANCE
ALTER OR ABB '1 O MECIL
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER 10.001 CFMI
EKHAUSTROOD(W/DUCT)
HEATING UNIT LTO 100,00t) 111111
HEAPING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RTSID)
,POILER —COMP L IHP OR 1(0,0)1) OTU)
BOILER —COMP (OVER BgJXV B IU)
AIR CONDTIIONER
NEW RESIDENTIAL MECIL SQ. F4.
TOTAL:
OFFICE
FEE
FEE
LU ELECT' PLUMB h1ECll
W
11 ❑ ❑
JOB DESCKIPI HJN
RESIDENTIAL
❑SITOWL.
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RIi-PIPE
❑MUUI'1-UNIT
❑STRUCTURAL
MODIFICATION
0INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
I] SWIMMING POOLS
❑ BATH REMODEL(REPAIR ❑DEMOLITION
❑ O')'HT;R
COMMERCIAL:
D�BLDG/ADDITION 0DE,101.I1 ION
TENANT ❑FOOD SERVICE
SQ. IT.
SISQ. IT.
2 /�VAI.UAI]ON
Oo0
STORES '1'YI'L C(lNs'I'RUCI'101
OCC. GROUP ^ A'N,., r
BUILDING DIVISION MUS
PIANCHLCK FEE
ENERGY FEE
GRADING FEE
SOILS Ir17E
PAID
Dam RccnfilM
10'TA;,
BUILDING FRE
FEE SEISMIC FEE
ELECTRIC FEE
I'LUMBING NEE
MI IIIANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION ITL?
PAID
Date ReceiptN
/- Z6.' Ov-29Q