99080084APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
rBBUILDINGA
ITY OF CUPF.RTINO - ROD. n1NG-RLKCPR
BUILDING DIVISION APPIACM'ION/PERMIT PLfIMNINf.-M1II!CHA:
BUILDING PROJ I?Cq'IDEN'
DURESS:
�.. � 2� � S � ✓n/S C/c 8 G . S�IJ/O
OF Gd-4P*IV J
❑ Consultant Fres Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT
I hereby off. that 1 am licensed unique plovisinro of Chapter 9 (commencing
�QZ with Section'7000)of Divivion3.fthaltuniea,a.nd Pnsfes.ions Code.andiryllech,cm PERMIT ISSUANCE
C, 2 In full foree med uffcel.
F<UU I.icemse Clms Lic.p APPLIANCES - RESIDENT^
6 a Date Cnmmcmr
ARCHITECTS UF,CLARA'f10N PANELS
FO vvii'Z. 1 undroard my plur, shall beaver! as Public record, UP'1'0200AMPS
N
O 4—
F h F �; Licensed Pmfczzional
yy .J
OWNER -BUILDER DECLARATIONheComem
G�
C Q 1 hereby v(Gnn than I am encntpt feat the Canuvctur's License hew for the
X O m U following renvnn. (Set, a 9113 I.S. Husincsx and I'n:lcx,ions Cada. Any city or county
,J:
3 a vFi which requires a permin to consumer. uJim improve, demolish, or repair any structure
0gpriorm is issvaocc aisssrtgmor,the'.,limmufmsuchpemriuo Glc. signed smament
that hems licensed p.meant e, the provisions oflhe Connector's License Law (Chapter 9
`x; RmmnencingwI'll Smtion 91X10) of IN vision 3 of the Emiar,, and Professions Code) or
a a e tY that he is exempt deefrom and the basis for the alleged ascription. Any violation of
X m a Section 9031.5 by any applicant fors Fermin subjects the applicam no a civil penalty of
v, a ..or than fume hundred dollars (55110).
z = c [] 1, as owner of the property, or my employee, with wages as their sole coml:eoeatloa,
p., will do the work, and the stiJ
cture is not intended or offered for sale (See.
awl m and Professions Code: The Contractors License law dues not apply to am owner of
d 3.. property who builds or improves thereon, and who docs such work himulf or through
his own employers, provided that such impmvemenm are riot imended or offered for
sale. If, however, the building or imVrovemem is sold whhln one ycut of canmletiou, ma
ner-Wilder will have the burden of proving that he did nor build or improve for put -
Free of sale.).
1, as owner of the property, am exclusively contractingwith li'enccd Cnnur i i cia n ns
construct the project (Sec. 701 . Business and Profmzions Coder In rs Li -
crave Law does not apply to an owner of property whe Wild%(iro improves thereon, and Q'Iy.
whocontnms for such projects with a cemmangs)Incensed prom untto the Contectm^s
License law.
'l l nm cemnn under Sm. ,B& P C for this reason
all Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declureiunr.
I have and will maintain u Cetiol,ane est Csrasv:Il is self-Invnre far Worker's Compen-
same. as provided for by Section 3700 of the Labor Code. for the performance rt the
work for which this Permit is ismcd,
ED 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Lure, Cale, Ibr the Perlmnnn"or the work for which this permit is issued.
My Workers Compensation Insurance'artier and Policy number are.
Cork' Policy No.:
CERTIFICATE, OF I;xl:MPDON FROM WORKERS'
COMPEN SAT]ON ^ NSU RANCE
(I his section need tan W completed if permit i, for ere hundred dollen (s Ian
orlcss.)
I certify thatin the performance of the work (or which this permit is issued. I shell
urn eemployploymany person in any manner xu as to become subject u) the Workers Compete
Z xmma Laws ol'Cab forms. Dare
2 Applicant
z NOTICE TO APPLICANT IL after mathi
king s Ccnifirme of fsempninn, you should
become subject to the Worker's Compensation provisions of the Labor Cede, you must
I'orhwith Comply wi it, sucb pruvlsinns or this punand shall be deemed revoked.
LIJ
C'. a
.=z CONSTRUCTION LENDING AGENCY
V O Ihereby affirm that there i, a construction lending agency for the performance of
F" the work for which this permit is Issued (Sec. END. Cls. C.)
C) U Under, Nunn
Q
L31 Lcrulve,Address
P. 1 cmify than I have read this applic.d mn and sea that rhe above informal is
(✓ IZI rten. 1 agree to comply with all city and county national a and star' laws retin
lag m QTl'
U {Z building numruction.and hcrehy at,Zuca reper,rumtives of thio city to enter vi the
above mentioned property for inspection parwrre,.
(We) agme In sme. indemnify and keep harmless the City of Cupertino against
liabilities judgments, eras and expresses which may in any way accove agmen said City
in enmcyn'nec of the gr nnting of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
I SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or future building rampart seat ord
r handle hHeaousmaterial
us dcliueCost by the Cupcnino Municipal CoChapter 9.12. and the Health andd Safety
�ndc. Semon 25532(.)?
❑Yes ❑No
Will the applicant or future building occupant use equipment or devices which
mit ha'ronluus all curl: elillumv a, Joined by the Buy Area Air Quality Management
Di.mncR
C3 Yes ❑No
I have read the alliolum rmr'rids tcquimmenls under Cbapmr 695 of the C+li-
temin Deal, & Safety Code. Smtirnx 15505. 25533 and 25534 1 arelci umd dale if fire
building doxy nal cueremly have s lunamt, that itis ,in, le,prequ ility us ready 'Ile neculwnl
of the requirement, which must be mel prior In issuance of a Certificate rf Occupancy.
OVER IMOAMPS
SIGNS ELECT RUAL
SPECIAL CIRCUIT C
TIME METER OR POLE
POWER DEVICES
SWIMMINGP LELF.(
..........Wffc Es
NEW RESIDENTIAL ELI
SQ FT.
ALTER - DRAIN&V t trial
RACK FLOW PROTECT. DEV Gfw /
DRAINS- FLOOR, ROOF, AREA, CO H'
FIXTURES -IT:R TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS,_ EA. SYS I EM-OV17R 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA,. 200 FE
WATER BEAT 17R WNENI'IF.LECTR
WATER SYmmORFATING
WATER SERVICE
NEW RESIDENTIAL PLMB, SQ. F3'.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT ('10 1 L000 CFM)
AIR HANDLING UNIT (OVGR 10.000 CFM)
EXHAUST HOOD OVIDUCT)
HEATING UNIT (TO I WA0) BTU)
HHAHNG UNIT (OVER EXL000 BTU)
VENTILATION FAN (SINGLE RESIT)
BOILER - COMP OHP OR IMP" RTU)
BOILER - COMP(OVER IWAR)
AIR CONDITIONER
N'l W RI?SI DI'NTI A I. MLCI1. SQ. IT.
TOTAL:
` . & J
ZS -OJ
BUILDING PERMITINFO
BLDG ELECT' PLUMB NIEECCIT/
E E LT
FEE JOB DESCRIPTION
RESIDENTIAL
❑ SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE.PI'E
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑IN'T'ERIOR El CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
C1 BATH REMODEL -REPAIR ❑DEMOLITION
❑ OTHER
�h
EW BLDC/ADDITION ❑ DEMOLITION
[I TENANT ❑17001) SERVICE
1 IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA &SQ. ET.
01000 OOV{^/
FF:E
V
BUILDING DMSION FEES
PIANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEF: F_
PAID
Da¢
BUILDING FEE
FEE 5CONSTRUMION
H
E
IEE
ONT XI ATIONPEG t
PAID
Date Recdplk
ISSUED
L