S 1299APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING. RLEC'IN
BUII,UINto DIVISION APPLICA'I'IONIPERMIT r! uSmuNflnr511 .r!l
10� 15' orowtYbM.e Dos.
ASHER:
S M. Cemk..
E2
I washy ulRnn mal I nm licenced ower pmviuiona of Chapter 9ommon'Iag
OnZ with Scuion 70norfDivisi,n 3ofthe Brine ed Profcxxiom Coda, untmy license is
�_in full fi,rcc nnof off G.
41^
n UF' License Clan. Lic.p O
m z Wy Dole Gmwctor `/
ARCHITECT'S DECLARATION
~
z t2 Z I Oldccaand my pmol'hall he used it' public rccools
OZ—J
Licensed Ym(msi0nul
Oat lam exempt
m CLnRA raON
C n Q I hereby .(fuss that 1 1 exempt from the Gnnlmcl,r. License c 1, , for the
L O following reason, tg rod, t Tal Basic... and improve.
sinus Gale: ,,i city nr county
W 3
U. N which teyuirca n permit re a,mwcL alter. improve, h permeh, or eclair any statement F�ere
Oe prions lx is.uuncc.nbo requires the applicant for such permit file aligned aaemam
�W} Oml be is licensed pursuant It, the fir ..i.,nnvm the Conlmchrrs Lieena Law (Ch,acr9
W C) (commencing with Section 70)0) of Division 3 ofthe Business and Pn.fcsslons Code)or
myon that he Is exmup thercfnnn mW the hadb, for the alleged ewhaption. Any violation it
W=to Section 7031.5 by any applicant Iia a permit subjects the applicant o a civil penalty of
row marc than rove henthcd doll., ($500)
i=0 C1. as owner of the property. or illy employees with wages as their site crnmenantioo,
F- w 11 Jo the work, and the saucam is not intennedor offered for sale (Sec. 0011, Business
a 3 mand 11 1o.xionx Code: 'rhe Couaaemr'e Licemc Law apes ern apply or an ,want of
property who builds or improve. thereon, and x ho does such work himself ,r through
his own employees, provided that such improvements are not intended or offcted for
sola IL however, the building,, improvement is sold within line year,( completion, the
ownerbuilder will have the burden of proving that he did not build or improve for pur-
pow of sale).
C 1, as mvner of me propeny, am exclusively concreting ,with Lcen.ad a,ntmamrs a)
msauct the Pl ojmt Ne, 7044. 13,...har, and P fessions Coday The Carmeln's Li-
ge law does not apply to an owner of property who builds or improves ihere m. ;aid
who contma%(,r such pmjecn with a cnmranmlx) licensed pursuant to the CcntmemVs
Licca law.
C I at,, exempt under Sec. ,B&P Cfor mil mason
"OX--nrla 9sm14.
NA(7OR'F NAMP_ LIC NO
❑ Consultant Fees Paid by Applicant (initial)
10TYJ ELECTRIC PERMIT I FF,E
FERMI IISSUANCE
APPLIANCES - RESIDEN AL
PANF.1 S
UP TO 200 AMT'S
201-100AMPS
OVER IlNX1AMP5
SIGNS ELECT RICA],
SPECIAL CIRCUITIMISC. f
TIiMP. METER OR POLE INS r.
POWER DEVICES
S W IMMIN(11'001, ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL CLEC? R SQ FT.
IOwner Urate
WORKER'S COMPENSATION DECLARATION
I hereby union under penalty of perjury care,( the following Jcclunnions:
I lover mJ will mainmin to Ccrtibcae of Continuo o1bin.ure for Worker's Colnpen-
sarear, ns provided forby Scetion 39111101 the Luhor C,Ac, for the perfom,unw nl the
work for which this worrit i. issued.
C I hive hall will hainaiit Workers Cnmpensal inn Insurance, as rominced by Sen inn
3700 of me Lefror Code, for the pertunnnnce of me wad lin which this permit Is .... uxL
My Worker', Compalturn Insurance carrier and Policy number arc:
Carzice I'olky No.'.
CIiNI'IFICAIE OP EXIiMIT10N FROM WORKERS'
COME'YNSNHON INSURANCE
(This.aetlon neral nor be nnnpleRN ifthe pm1il i. far onehuntrcJ dollars (S 11N0
or Icy..)
1certify bah inthe performance 01'me work lin which cels permitrlissued, I shall
not en,piny xray p^nn in xray manna w m to become whjecuo the Workers' Compen-
O 'Z, ration laws of Calil"hear Dole
Z O Allidwant
N(YI'ICE TO APPLICANT: If, after making this Ccnifieme of Esanpuon, you should
I" 4 Mame object to the Workers Cnmpenwdon pmvi.ions nI the Lubar Code, Yon ,at
ail forthwith ceotply Ido%.ch provisions to prom, shall he deemed revoked.
aQ
z CONSTRUCTION LENDING AGENCY
UU
O Iherchy nllirm that there lxuum.wetinn lending agency for perh,nnvncc of
it. P: the work for which this permit ix is,awd(Sec. 30)), Ci, C.)
O ULeader', Moore
Lender's Adds...
a I certify that 1 have mad this application and .am Thal rhe Abs ve in(ovnunon is
nF.1 h corral. I no In comply whh hit a'ny and our my out lnanca and sate louse relating to QTY.
U Z building construction, and hereby mahmW mpreeenati acs of this city a enter upon me
aMw cmlO led pmparty fill imprGi,n larlow
a
(We) ugme m save. indemnify mW keep hamdet''he City of Cupertino alai til
habil ities, judgment , costs and expenses which may in any way accrue against snit City
in call open, rQ.e)rc griming of this Imrmil.
APPLICANT N )F.RSTANDS AND WILI. COMPLY WITH ALL NON -POINT
ti.�t Appli4'RIf�S/�Imclor'� - — Dmc
/ABI%)US MATERIALS DISCLOSURE!
Will the applicant or fuace building racupant store orhuwlc h rmelous matcnal
as defined by the Cupeninu Municipal Cone, Chapter 9.12. and the Houlth and Safety
Gale. Salon 25532fa1!
❑Yes 0 N
'Win the 131 loan( or hmuu had ding (recall u,w echipment or devices which
mil hazardous air commitments as defined by the Buy Arca Air Quality Management
Dolrict"
CYe, Fl No
I lave lchd him nuardnns n anhals calunmacas color Chapter l 95 of the Calm
(emir Health & Safety Code, Sections 8505, 25533 wJ 25nel, I umlenaw mal it me
heldlog Joel nm curzewy have It taws. that', is Try resryaymility to notify the ccemanl
of the oximacme d which must he del p^or,, council moo Cenmeva of O"aprney.
PLUMBING PERMIT
PERMH EtUANCE
ALTER -)P IN A,VJZH -WKI ER(EAI
BACK PLOW ,CI�VICEi
ITS I DIES -
GAS - EA, S'
GAS - EA. S
WASTE
SEWER-SANI'1'Ally-S EA. 2B11'1'.
RATER BEATER WNENI IF,LECT
WATER SYSTEM/TREATING
WATER S17RVICE
NEN' RESIDENTIAL PLMB. SQ. IT.
MECI IANTCAL PI7RMIT
VERMIT ISSUANCE:
ALTER OR ADD In MECH.
AIR HANDLING UNIT fl O 10.06) CFM)
Allo HANDLING UNIT OVER 10.000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT LTO 100,000 BTU)
HEAI INC, UNIT (OVER 100.B)U BTU)
VEN'IILAI ION BAN (SINGLE REBID)
BONAER-COMP(3HPOR I00,000 If U)
BOILER-COMP(OVER 110,00 BTU)
AIR CONDITIONER
NEW R1i.SIHENTIAL MECH. SQ. PI'.
OFFI
.... 8,,..., 1299
NI ANY NO. APPLICAI ION SUBM1'1'IAI,
.� n
NICCowlRol. a
1:1
97 24
BUILDING PERMIT INFO
BIJU ELECL PLUMB h1ECH
JOB DESCRIP'T'ION
FDWI,
C KITCHEN REMODIiI,
�C DITION
01'LUMBINGRE-1'11313
MULTI -UNIT'
CS'FRUCIURAI,
MODIFICATION
C INTERIOR
CCIUMNEY REPAIR
IMPROVEMENT
[]SWIMMING FOCUS
C BATH REMODFLIREPAIR C DEMOLITION
COTHER
COMMERCIAL:
F1 NEW BLDG/ADDITION ElDEMOLITION
CTIhNANT ❑1`001) SERVICE
IMPROVEMENT
C OTHER
SQ, Ff. FLOOR AREA SISQ, Pit
bt•o
m:E -� �1 �S•S
VALUATION
STORIES 'LY111 it CONS'I RUCON
OCC. GROUP AIN
1
BUILDING DIVISION ITIS _
1'IANCIIEC I iE � -
Gltnl .1� . i
SOILS
PA 'ID
Dm a
BUILDING FEE .p�
ITE S171SNIIC FIJI
ELECTRIC FEE
PLUMBING FEE
MECHANICAL ITH 5O
CONS'fNUCION'I'AX
HOU MI'1'IGAI'ION 117E
PAID
Dae Receipt x
I'll.
ISSUANCE DATE
Z ZfZ� 2r
AG Y'.i
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