S 1668a
s
I
0 0
I1
W �
U0
01
>I
G
&PPI IrAtill FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING. ELECTRICAL
Rl1u,DING IIVISIUN APPLICATIONMERMIT PLUMBING. MECHANICAL
nUTAmG PItO,IH4'P IDENTIFICATION
Pfigff NO. 1668
L—
BUILDINCADIJ I"SS:
SANITARY NO.
APPLICATION SUBMITTAL DAP I!
OWNIiH'S AEI:rt PIIONe 145-6�Z
W. V
CO T AC O :S@'NAN1F LIC NO:
ll0�.�1
N/C
❑
CON'I'ROLa
S��S
V
,CIII'I'I:CTIENGINIiER; LIC NO:
G
AUI RP„$U %
//
coNT'nCl': rxoNe:
yAA ������Q�
❑ Consultant Pecs Paid by Applicant (Initial)
BUILDING PERMIT INTO
BLDG 17I EC`I PLUMB MFCH
C� CT L�f— E2-
LENSED CONTRACTORS DECLARATION
1 hereby affirm That 1 am licensed under pmvi,ions Of Chapter 0 (commencing
wof Soli 07000).11a.lsion3oDhe Hnalne.sand Pmfinelnar Codgmuf Illy lTceno, is
�RQ 5NO!,
Ise Mass 1] IJ0.M
Due Comucmr
Q'rY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI, ❑KI'I'CIIIiN NEMODI.1.
❑ADDITION ❑PLUMHING RE-PIPI!
❑MULTIUNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR 11 CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOIS
❑NAT'li NIiMODEVREI'AIR El DEMOLITION
❑OTHER
C Sv'
PERMIT' ISSUANCE .7
APPLIANCES -RESIDENTIAL
ARCUITF.CI'S DELLA 'PION
I mmdentic d ry,lans shall be mcd as public records
PANELS
UPTu 21x1AMPS
LlcoowJ l'mfoa,ional
OWNER BUILDER DECLARAI ION
1 hereby action that 1 am exempt from the Conlmaors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which rr la!res n permil to construct, alter, impmve, don mbull. or repair ony structure
m Ble ami recd ntxter"Ill
Thaihe itscco,d,mr ralal ms lhcepp-offor such pcnntl b
tome of Doonrn[ theeBusin sand Prof Law (Chapter 4
thatheiscing with
that he is exempt barefoot and of DivislnfruRhceged Business andonnf Anyvi Collator
Nat he is exempt Therefrom ane the basis for the alleges applicant to Any violation of
Sorel.. Aham be made for a it subjects The applicant muCivil penally of
not marc thne five I bendreJ dWlata , clu1).
cmn,ensness
1] Lo the work, ndthlle P-11,1111,-1myot intends oithlered for sale
not intended Law rdoes of a ply to al4.Businms
will tln thework,Cusle: he Con, istractors
and Professions CnJc'Ihe Comuctoh License law Nes not apply m on nxner of
,.NO, who build, or improves thereon, and who does suchwork himself or through
his awn employee., .....Wed that such improvements are not intended or offered Nr
salo.11; huwcver, the hnllJing nrinmprcwcnmm is sold wish none yenrnl'cotnPletinn, ll¢
wner,hullder will have the burden or proving that he did not build or Improve for par
posenl'sale.).
-11, as Owner of the proper,, am exclusively contracting with licensed contusion m
construct the project (Sec. 70,W, Business and Pndessionx Cale:)'Ihe Commonly's Li.
,jon Law does nm apply to annwocrof Property who hnilds Or improves ffiCri unit
whao,1, for such pmjecla whin,onnatio (oTwo edpnrsauau,t,Co..arc
License Law.
1 am exempt under Sec. , B & P C lin this reason
201-1000AMPS
OVER IINNIAMI'S
SIGNS ELECTRICAL
SPECIAL CIRCUI'IIMISC.
1F,MI'. METER OR I'gl.EiNST'.
COMMERCIAL'
E FI LDG/ADDITION ❑ DEMOLITION
NANI' ❑ FOOD SERVICE
IMPROVEMENT
-;it
�OTHI?����
POWER DEVICES
SWIMMING I )OL 111.1("TRIC
UfiJ!Tl-SWITCHI '-FIXTURES 2
NE RI'SIUENTI R SQ FT.
SQ. TTI'. FLOOR AREA
I 2 -
&/SQ. Fr
l.' f 00 t
'
TOY 1.: `�ss ?
J
- -
Q'fY. PLU TNG PERMIT' FEE
PERMIT ISSUAN °
ALTER - [TRAIN& WATT! )
Date/lir
A�' .UATION
7� a v
� ) IVU SYPH CONSTRUCT ]ON
rC V
OCC. GROUP AIN
I/�
'i
caner
WORKER'S COMPINSATTON DECLARATION
I hereby aff m under penally ul' scgm, ane of the fallowing dxluumionr.
Ihaveandwill maintain a CeniGcale of Cnn.senuo self -insure for Worker's Compen-
scion. as providW for by Section 3711(1 of the Latham Code, for the performance of be
work for which Nis permil is I ... ed.
I have and will maintain Worker's Compensation Insurance, as raryireJ by Section
3700 of the labor COJe, for the perfomnn¢cnflhc work to which lis pcnnll i. ix,ual,
C. Work 's CnmP:ma'm1 surencc capp Sly Policyn
Carver. t—`Policy No.: BHm�S'P�.14Z-li
CERTIFICATE F 1!). !I AiIT10N FROM WORKERS'
COMP17NSAI ION INSURANCE
(Phis section cold not be conmplcmA if the,ennil is fnrttno hundred dollars (SIIN)
or less.l
I unify that in l in any mannerme okes'Comen-
rsit us twmkfm suwhibject
not employ any ,conn in any mannenn ax m become snhjcm In Nc Workers Camper,-
oadon Laws of C.Ithimill Date
Applicant
HACK PLOW PROI'I!CT, DI ICI!
DRAINS -FLOOR. 1,001FAREM4,IIIND
FIXTURES - PER TRAP
OAS -IiA. SYSTEM.I INC. J OUT LIm
MS-13A,SYSTIiMGV1iRA(EA)
GREASEUCDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FF. IS
GREASIi'fRAP
I'I,ANCITIiCK PI!E
SEWER -SANITARY-S'T'ORM IiA. 200 IT.
ENERGY ITE
i
WAT17R HEATER W/VENTIDELECTR
GRADING EEE
NOI'ICIt Is) APPLICANT II; after nmAing this Cenitidatc of Exengaion, you should
becmne Object m the Walker's Compen,ulinn pmvixio o of the Labor Code, you Inusl
forthwith comply with wch provisions or this,ormil shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
n lenngagency for the perforrienc, a
I hereby aflun Pouhere is amnsImoiodi
the wutk for Odell IhiR sa not i, iv,owd (Scc.3097, Civ. C.)
Lender', Nance
WATER SYSTEMII'Iil!A'1'ING
SOILS FI?li
WATER SERVICE
PAID �/� �fL�V_.1_L7.�
'72/'
bb
NEW RESIDENTIAL PINE. SQ. Fr.
Dat Raeaptp
TOTAL:
Lender's Address
infnnmmtion is
TOTAL:
BUILDING FIT;
632
I ecnify Ihm 1 have mad Nis application and on¢ Ohm the aMwe
Correct. l agree to comply with all city and county ardamces and state laws actuarial
building construction, and hereby mhntirc wpoescnmtives of this city loaner upon the
abnvonmcntlOned pngmry I., alpen!on purpose,.
(We) agree lo, lve.'mdemnily end keep haonlcas the Cil, of Cupertino.,mII,l
liahilimics,judgmenrs. coos and expenses which may in any way accucngaina mid City
in consequence of the grunting of this permit.
APPLICANT' UNDERSTANDS NO H.I. COMPLY WITH ALL NON -POINT
SOURC : EGUL .1 HI 1 S
QT'Y. MECHANICAL PERMIT FEE
SEISMIC ITH
-
p
15,3
PERMI'TISSUANCE - So
LLECTItIC hili
['�
—/S, 32
ALTFRORADDTOMECTL
PLUMBING PEE
AIRIIANDLING UNIT ('1010.000CFM)
MECIIANICAIJ'EE
AIR I IANDLING ON fl,(OVER 10,M)OGPM)
CONSTRUCT ION TAX
marcnfA,,I m omuam Lye
ZARDOUS MAI17RIAI S DISCLOSURE
Will theapplicumser lance bnlldingrccupanl,mre nr handle hvanlona material
as defined by the Cupcu rat Municipal Code, Cha,tn 4.12, and the IlwTth and Safety
Co de, Section 25532(a)fHEATING
Yes ETN—.
Will the applicant or future hullding occupant use equipment or devices which
nil hw mhm, air uonmnnntuns as dalinal by the Bay Area Air Quality M nu,nownt
Dkincff
[-1 Ye, FT55
1 have road the mecialom mamriaN requirements ander Chapter 695 of the Cali-
fomlu,doc,&Sanity 111 Smdom'255115, 25533 and 255341undmxtunJ Ihm II the
building dam not cumn0y hav mnuu6 Wmhis my rc,pnnsihilily In nnllly the nccupnnl
u
of IM ncimms whi' md,pri n aux of It Csn!fiwi I d 0c[
EXHAUST GOOD OVIDUCT)
HOUSING MITIGATION FEE
HBA'I'INC, UNIT (10 100,0Y) IT TO)
_
UNIT (OVER HIP000 BlM
PAID���� Receipt #
a
VENTILATION FAN (SINGLE RESID)
ROILER (1111' OR IIMI,IIINI li'f117
'TOT•AL:
BOILER- COMP (OVER 11x1,000111'(1)
AIR CONDITIONER
ISSUANCE: DATE
ISSUED BYC,.,/n` H=W O'L�
NEW ItIiSIDENTIAI. MI?CH. SQ. PT.
TOTAL: / s )�
O amhoriz xgcm Tae
OFFICE