S 1888APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIRICA], PESLI'NO. I 8 8 8
APPLICA'PION/PFRMIT PLUMBIrvc-MF:CxnrvlCnl.- 1
„BUILDI(Y'�j DIVISION .NUII,DING,YR(1JF.0"P IDENTIFICATION
'DRESS.S.-
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Fl]nNF I CON'TRACTOR'S NAMIe LIC NO
Z
UO3 1 ❑ Consultant Fees Paid by Applicant (Initial)
1 hereby at W 1 am licensed under Prop,,Wom tm
of Chard, 9 (eonenam,
AaZ frmm with Section 7") 1Dlvision3oflhE Bappeosand Ppressidns Gale,and myliver, is
F1_ In full foreelarde0 _ 38,.�'bbb
6UU License Licq—��►���—
y Z G
Datea te— Conte' S--�'U-lY
4¢ ARCHITEC'T'S DECLARATION
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W6
OWNER -BUILDER DECLARAION
CyG� Q i hereby milliony mI nm. exempt from bd
the CnnTumr's license Law for the
1d O acU following reason. (Section 7031.5, Business and Pmf sions Gale: Any city or county
f11 a W y which requires a permit to construct, alter, imp r, demolish, or repair anystructure
point ea its,al r , 'lie appirant peraid ton file regand,lishapart
my'
chat he f' d,m tt he provisions; Hh Connector's License La(Chapter9
�QO(a.pormord, with Sir IIMW) fD is T critic Business dP I ex,ions,E d m-
L G c that I pt therefrom d thebast f the ex la Any vioplem of
WSect 7WIS by ny ppl c t l perm l 1p t. th aPPI art t I Penalty of
not more Than five hundred dollars South).
^yd
E] Las owneref Nm
e prappay, dr y employees with wuges as their side comp,osation,
FO wi 11 do and work, and the structure is nil intended or offered for safe (See, 704, Basin,,,
ti
ro and Proof es -.ions Code: The Conmachor's Livens, Law does not apply to an owner of
pro perry who builds nr imppves therene, and the does such work himself nr through
his own employees, provided that rich Impmvemmots are ma intended ter offered for
sand. If, howeveq Wo building nrimpmvemun fearful within one year al econnection, the
cr-builder will have Ilio burden of proving that he did not build or Improve for pur-
pose of sale.).
I, as ownv of lid pmpeny, con exclusively "criterion, with licensed re nnacwrs m
on Omer the prjde (Sec 7"44. Business and Prcdmsler, Code:)'Ih, Connacldra Li-
reLaw does ndlapply toanowner ofpropenywho builds orimproveslh,mon,and QTY.
ox In, am riles for mch p,,,a', .,In or conlmernes) licensed pursuant to the Commuter's
I.iceme Low.
I am exemp, ander See. . B & P C for anis renann
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby will
cam under penalty tepe jury one ofmc following decmuss Ch
I have and will mainmina Certifcasof Consentucsead fiurefer Worksre near li-
salinn, as providul for by Section 371Ns of the Lubar Cade, fur me Iwrformnnce nl' @d
work for which this permit forssued.
A1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofihe LabnrCode, for the perfnnnenec of the work for which this permit is Issued.
My Worker', (l( pensadon lainm carrier and Policy counter or¢
Camk,L.0 A_T, ay D��' Loch, No.L 9kz6D 2.1 J-5+
CERTIFI ATEOPEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he complded[fate permit is Inane, hundred dollars ($ 100)
ode's)
I certify me in the performance of the work for which this permit is issued, [,hall
amt employ, any person in any manner so as u' become suniec, on the Workers' Cnn'pen-
o z nation L[ dl'(AJ4'c' are D
yy Applicarn L
G ti NOTICE T.APPPLICANT: IL after making whir Certllicarrd of Esemplinn, you should
y
EN•' w"'
doctrine subj whe Winter's Compensation provisions of the LOMa Coda, you must
.IdnM1with compp toly with such provisions or this permit shop be deemed revoked.
LLCCff CONSTRUCTION LENDING AGENCY
d
1 hereby script that there is a e arstraction lending agency for the perfnnnnnce of
W C) the work far which nits permit is issued (Sed. 3097, Civ. C.)
Lenders Name
W Lender's Address
1 parodythat Ihave read misapplication hit lmthat th aM fntatlnis
h ear , 1 agree W 'm ply withan ca,and alably pulfirearep, and.title I '.clef gin QTY.
:.1
building emostneriona, andl by conn p t f coof (his any1 letup wore
ableve-martioned pmpeny for inspection purposes.
(We) agree: te save, indemnify and keep harries the City ofCupeninn agalnss
lialudities,judgments, costs end expenses which may many wily acemeagainsl said Ciry
in nosed ucnce of the granting of thin permit.
APPLICANTUNLESS ANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signata,c,,l pplicanl/Commcmar Dec
HAZARDOUS MATERIALS DISCLOSURE
Will the applife rt of future building ucenpanl stare nrhandla hamrdnus malarial
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes ❑No
Will the applicant nr Ibluo, building durpnnl use cquipmem be devices which
+nil haz ,name, air comminuted, as detined'by the now Arca Au Quality Mo er,apent
Basila
❑Yes E] Na
I have pard ltte hazardous maleriuls myuirsmcros node, Chapter 6 95 of the Cud -
home, Health & Safety Codd, Sections 25505. 25533 and 25534. 1 understand mel if the
building docs ndmurrenlly haves linea , that it is my respmnibillwy n' notify the Uceaptmt
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP'10200 AMPS
201- light AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUI CMISC.
TEMP ML I 14 OR POLL INS'T.
POWER DEVICES
SWIMMING ['DOL ELECTRIC
OUTLET'S-SWIT HES-FIX'I'URBS
SQ FL
ALA ER- DRAIN &VE N^
BACK FLOW PROTECT DEVICE b in )
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC, 4OUTLETS
GAS -FA. SYSTEM -OVER 4 (EA)
GREAS EJINDUSTRL WAS'I INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM PA. 200 FT.
WATER HEAL ER WIVF.NTIELECI'R
WATER SYSTEM,TREATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. UL
MECHANICAL PERMIT
FIRM I ' ISSUANCE
ALTER OR ADI'' O MECH.
AIR HANDLING UNIT (TO 10,000 CPM)
AIR HANDLING UNIT (OVER 10,"M CFM)
EXHAUST 11000(WIDUC7) aA ! ID
HEAL INO UNIT (TO 100,000 H'FU)
HEATING UNIT (OVER ITun RT2 2 AN'
VENTILATION FAN (SINGLE RES]D)
BOILER - COMP (314COR IFIX) RTU)- CFI I
BOILER -COMP (OVER 100,00) B'FU)
AIR CONDCHONEIt
NEW RESIDENT IAL MECH. SQ, FT.
0
FEE
COMMERCIAL"
❑ NEW BLDG/ADDITION [_1 DEMOLITION
❑TENANT [_1 DO DSERVICE
IMPROVEMENT
❑ OTHER
SQ, PI'. FLOOR AREA
VALUATION
iCK FHE
FRE
Receipt a
TOTAL'.
BN LEE
EE
PEE SI3 MICFEE
CTRIC FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dat,
I eel 'l -D
ISSUED BY: ���
BLDG EILLLLCCI
IlFrr \
YhUMH MRCII
El El
PEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHEN REMODEL
El ADDITION [_1 PLUMBING Rx -PIPE
❑MULTI -UNIT E] STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT DSWIMMING POOLS
'❑ BATH REMODEUREPAIR ❑DEMOLITION
OOTHER
'-^
�.l
2 J(
FEE
COMMERCIAL"
❑ NEW BLDG/ADDITION [_1 DEMOLITION
❑TENANT [_1 DO DSERVICE
IMPROVEMENT
❑ OTHER
SQ, PI'. FLOOR AREA
VALUATION
iCK FHE
FRE
Receipt a
TOTAL'.
BN LEE
EE
PEE SI3 MICFEE
CTRIC FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dat,
I eel 'l -D
ISSUED BY: ���