S 1106'PLICANTTO FILL IN INFORMATION WITHIN'REO LINES - USE BALL POINT PEN ONLY
ITY OF CUPERTINO
BLDG F,LLM
BUILDING. RLF:crR
BUILDING DIVISION
APPLICATION/PERMIT
PLUMBING-MECIlk
RESIDENTIAL;
J>
{ BUILDING PRIIJECT IDEM
IILDING D/ l
�Y
El PLUMBING R17 PIPE
7[� tsw„
❑STRUCfURAI.
.
VNER'S NAME:
PHONE:
CONTRACTOR'S NAME:
'Tv„ n 1L
40,0—)IT-e
.
CONTACT
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
DOZ with Section]000) of Division 3 ofthe Business and Professions Code, and my license is
in full force and ¢Beet.
License Class Lic. N
YY11
Date Contractor
•�-� ARCHITECT'S DHCIARATION'
rs¢4
I undervmnd Iny plans xhall focused as Fustic rcanNx
L
Licensed Professional
L f •,.l , Oat I ron exempt fo DECLARATION
4w, {. I heresy affirm that 1 am exempt from the Contractor's C's e: Any c law, for the
L VF. following reason ISttlion 703 t,5. Business enA Professors Code Any city or county
O N which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, oleo requires the applicant l'or welt permit to file a signed statement
3p0 that he is licensed putsounfinite, pmvisi... ,,Irate Comraemra Licence Laos, (Cla"er9
Y� (cnmmendng with Su:w7000)of Division Sol'the [to siness and Prnrccsinns Code) or
jC Ism lines exempt Iheenrrmn and the basis for the alleged exomp,ion. Any violation of
Ito Section 7031.5 by any applicant forapemti, subjects the applicant In u civil pemlty of
net mare Nan five hundred dollars (5500).
Cl (]Lae owner of the property, or my employees with wages as their sole compensation,
will do the work, and the stmcmm is not intended oro0eree for sale (Sec.7044, Business
L 3 and Professions Code: The Contractor Liccnxc law rims not apply to an owner of
property who builds ur improves thereon, and who does such work himself mr through
Ws own nntployces, provided that such improvmncies are and intended .r offered for
sale. If, however, the huildingor improvement lx xnld withinone yearol oneefre, the
caner -builder will have the burden of proving Ism he did not build m Improve lin pur-
Irose of sell
❑ I, as meet of the property, am exclusively contracting with licensed conmmmrs to
construct the project (Sec. 701 Business and Professions CW,:)'Me Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and QT'
who contacts for such projects with a eo ourno N licensed pursuanno the Cnmrvemrs
License Law. `
El Iant exantpt a Sea. 01 -. 8&PClbrlhixrwsnn
owner Dom
WORKER' MPENSAFION DECLARATION 757
L r yaffirm unJ Itenallyofperjury one of the following decimations:
❑Ih nd will maintain a Certificate of Consent self-insumfor Workers Compact -
sat imn, s provided for by Section 37W of the Labor Code, for the perfomansc of the
work for which this permit is issued.
❑ I have and will muinmin Workers Compensation Insurance, as required by Section
3700ofthe Labor Gxle, Iimthe Performance of the work forwhlch this pontiff is issued.
My Worker's Compensation Insurance career and Policy number ore:
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
('this section need rat facm,Eted Rise permit is form ahundreddollars 15100)
orless.)
1 certify that in the performance of the work forwhich this Hermit is issued, l shall
nut employ any person in any manners. as to bavern abi 1. tit,
l arks,,' Comper-
z satin. Laws .1 Calllnrnia. Dale
O Applicant )
y NOTICE TO APPLICANT: If, after making this Cemilicate of Exemption, you should
a 7 become subject to the Worker's Compensation provisions of the Labor Code. you must
fnnhwid, comply with such provisions or this permit shall he deemed revoked.
a
CONSTRUCTION anter lending
AGENCY
V p Ihereby hich 11t Nut..ere is tan (See 30 len ding agency for the performance of
ft, Iso work for which )hie permit is Issued (Sm. 9119), Civ. CJ
0U
Lander',Name
Addm
D.I Isnder'
I Address
certify that I have read this application and store that the shawl sus mininn is
N buildingteref agree to comply with all gnash carry epres ntaiives of and city
to nt r upin the ' Q'f
V Z building conmmction, and hereby authorize representatives of this city mennr upon the
.Move -mentioned property for inspection Furry,,¢
(We) agree to save, indemnify and keep hartnlcx. Ne City of Cupertino against
liubiliticsjudgroart, coots and expenses whichtnvy in any way usernme,ord,ind City
in caresmanum of the grunting of this i ornal.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RLGULATI \
I'
Signmre
unf Appb a tactor - Date
IAZARDOUS M . JAUS DISCLOSURE
Will, Doicaa or fmnre I ........at store or handle hurMous material
as defined the Cuperrim M ipol Code, Chapter 9.12. and the Health and Safety
Core, Sc ton 25332(a)4
Yes ❑ No
Will the applicant or future build; ng mcupun, use equipment or devices which
mit hazar arae, air contaminants as defined by the Bay Area Air Quality Management
Oinria?
❑Ye. 0 N
I have ream the M1:Ialloas mamri 55 ru4u5.533 an under Chupmr rvi of the Calie
or
gdoes & 9tfcry Cale,llyha a stereon, , that it
2.is y3 and 25534, to notify the
tlml if ant
bn tiding doesnotwhich have uta 1pior,Ixtaramy caf u Certificate
oifytlsmincy,
of the requirements which mum be trot prionoiscnance nfa Certifcar of (khntp:mcy,
Owner or authorized agent Date
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
SIGNS ELECTRICAL
'I'13MI'. METER OR POLE Ng'
,,,;,.a DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -17T V
NIiW RESIDENTIAL 1; AHC R
.,PCUMHING' PERMIT' t
PERMIT ISSUANCE
ACfER - DRAIN & VENT -WATER TER (EA)
RACK PLOW PRUIECI'. DEVICE
DRAINS - FLOOR. BOOP. AREA, COND.
IIXI ORES - PER TRAP
GAS - IIA. SYSTE -I INC, 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFIINDUSTRL WAS'I'1i INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT,
WRI'17R I HXI HR WPIEN'I dzLECI'R
WATER SYSTEMITREATING
WATERSERVICE
NEW RESIDENTIAL. FUME, SQ, FT.
I MECIIANICAL PERMIT
PERMIT ISSUANCE
A ERORADDTOMECII.
AIR HANDLING UNI'TT 0 111,01111 CFM)
AIR HANDLING UNIT (OVER I0j000 CFM)
EXHAUST How f iymucI)
I IEA'FING UNIT (TO 100,010 BTU)
HI?ATING UNIT (OVER 100.000 BTU)
VI?NTILATION PAN (SINGLE RESID)
BOILER -COMP OUP OR 100.1011 BTU)
HOILER- COMP (OVER 100.000 RTU)
AIR CONDITIONER
SPIN IIESIDEN'I'I AL MECH. SP Cr.
1106
C
BUILDING PERMIT INFO _
BLDG F,LLM
PLUMB MECII
GRADING PEI?
JOB DESCRIPTION
RESIDENTIAL;
J>
0 SFDWL
❑ KITCHEN REMODEL
[]ADDITION
El PLUMBING R17 PIPE
❑MULTI -UNIT
❑STRUCfURAI.
I.1 CI'k'C FEE,
MODIFICATION
❑IN'IPRIOR
El CHIMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑ HATH REMODELIREPAIR
El DEMOLITION
❑ OTHER
W�
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑717NANI' ❑ FOOD SERVICE
IMPROVEMENT'
❑ O'i'HFR
SQ. IT. FLOOR AREA 5/SQ,
PAID
JAN., -5 ANS'D
Me Lq� Urvlrnr'p7W
STORIES 11 TYPECONSTR.
PLANCHECK FEE
ENERGY FEE
GRADING PEI?
G
5011 S FEE
J>
PAID
Date
he t t
TA L:
BUILDING FEE
SEISMIC FEE
I
I.1 CI'k'C FEE,
1'LIJMBING IIG
MECHANICAL FEE
CONSTRUCTION TAX -
HOUSING MITIGATION 1911:
PAID—
Dore
Rac1PI B
TOTAL:
ISSUED BY.
ISSUANCE.DATE
��