S 1082APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ElEICFRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MF:LLAIMCAL
BUILDING. PROJECT IDENTIFICATION
PF' ITNO.
J 8
1 1 b
BUILDING ADDRESS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
O�
OWNER'S NAME PHONE:
' ARCH ECr/F.NGINEF.R: LIC NO:
CONTRACTOR'S NAME: LIC NO:
ADDRESS:
NIC
�k CONTROL.#
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`l/J/1V_
CONTACT: PUONE:
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❑ Consultant Fees Paid by Applicant (initial)
BUILDING PERMIT INFO
DG ELF LD Mecx
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nm I am licensed under provisions of Chapter 9 (commencing
Z wlth9oction]Ba0)nf Doi1um3nr Mc euslnesnand Professions GWo.'und my license is
I. full function eRcm.
V License Class Fit. It
W Dore Contractor.
QTY ELECTRIC PERMIT FEF.
JOB DESCRI 'ION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
DADD]TIDN L1 PLUMBING RE -PIPE
❑MULTIUNIT Ll
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
I ROVF.MENT Ll SWIMMING POOLS
TH REMODEUREPAIR 0 D17MOLITION
El OTHER
PERMIT ISSUANCE -
APPLIANCES -RESIDENTIAL
so
y ARCHITECTS DECLARATION
Z I undcrswnd my plans shall he used as public remNx
PANELS
UPT02(MIAMPS
Y�1 Lreenxd Professumul
j OWNER -BUILDER DECLARATION
6 I hereby e1Bmt that 1 am exempt from the Commctors Liesese Law for the
U (ollnwimg mason. (Section 71111.5, linsincss and Pnsfescras Cock: Any city or county
F which o tires a
mQ y Imrmit to ennshvet, alter, improve, demolish. nr repoie any structure
J prior to it issuance, also requires the applicant for such Permit to file a signedstatement
that he is licensed pursuant to the provisions of the Contmcmr's License Law (Chapter 9
O (commencing with Section ]tX1U)of Division Jnf Ne Business end PiaF.,mns Grle)or
Tthat he is exempt therefrom and the basis far the alleged exemption. Any violation of
fort• Section L5 by any applicantfor a Permit subjects the applicant) a civil penalty of
y Onore t]am Evc hundred doll ... (olsan.
❑ I. as Owner of the property, or my employees with wages as their vale compensation.
willdothework,andlbestrvcwreisn.tintendedorodemdformle(Sec.7t .Nosiness
and Professions Code: The Connector's License Law does not apply to an owner of
Property who builds or improves thereon, and who s dtwsuch work danwIl' or through
his own employees, provided tem such improvements am no imeoled or o1Bm1 for
sale. If,however. the building or improvement issold withinoneycarofemiadmion,lhe
ownaboilder will hove the marlin of proving that he did not build or improve for pm -
form of sale.).
3 1. as the r of
❑],ossinnerof theproperty,am , Besdusunit cnntaaing with licensedcatnteuns i.
(Sec ](Wan Business and Professions Cod,) ens d emnsmrs of
cease law dace not apply to an owner ofpmp:ty who builds or improves thereon.and
who contracts fm such Projects with a ommactoo0liccowd pursemrlo the Contactors
Licenx law.
❑lam exec, rSee. ,B&P C Fear his mos
tat reao
Own Datc
' DECLARATION
WORKER'S ' 9iNSAr raw
E31 hereby affirm under penalty of perjury one of the following Jalarvtinns:
I have and will maintain a Certiftcamof Consent m self -insure for Warkerx Compen-
anion, as provided for by Scaion 3700 of One labor Code, for the performance of the
aerkfnrwhichthislaraitisissued.I
❑ 1 have oad will maintain Workers Compensation Immune. as required by Section
37W of the Labor Code. for the No-hrmnnce of the work for which this permit is issual.
My Worker's Compensation Insmance caoier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
or lets.) (This action need not be completed all a pemut is Goren hundred dollars g1Baan
(certify thin in the any performance ofthework for which this Wa issued, Corapn-
not employ any person in any mmner so) as m become whjed m the Workers' Cnmpcn-
vas of California. Date Applicant '
Appier �
281-Hu)AMPS
OVER I(XIB AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
it
TEMP. METER OR POLE INST.
DG/ADpITION El DEMOLITION
r(0 AA ❑FOODSERVICE
as, I RO IT aN
yr LV
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES 5
~
NEW RESIDENTIAL ELF:CfR SQ FF.
SQ. FF. FLOOR AREA
{e•J�CN�yJ(
f;/SQ, FL
L
QTY. PLUMBING PERMIT FEE
1'ERMI'I'ISSUANGIi
ALTER - DRAIN & VENT - WATER (EA)
VALUATION
�� `"Il —1
BACK FLOW PH(YI'GC1'. DEVICE
DRAINS- FLODR, ROOF, AREA, COND. _
STORIES TYPECONSTRUCPION I
FIXTURES -PER TRAP
GAS - ITA. SYSTFM-I INC. Y OUT I.HTS
OCC. GROUP AI'N
GAS -[ A. SYSTEM -OVER J (EA)
GREASIIINDUSI'RL WASTE INTERCEPU)R
GREASE TRAP
BUILDING DIVISION IDES
PIANCHECK HE �•
Ay
SEWER-SANIyARY-S I OHM EA. 210 tT.
ENERGY EEE
WATER HEATER WNENT/IiLEC1Jt
FITE
NMICGRADING
become( sTOAPPLICANT:IL aftermaking thisvisios Of of Exemption, youshould
Cake, you muss
become stomp m the Worker's Coons or
forthwith comply with such provisions or Nis permit shall ec deemed revoked.
is provisions of the deemed
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency hnthekerfnaremseof
the work for which this permit Is issued (Sec 3hD, Civ. C.)
r Leader's Name
� Lcndch Address
1 certify that I have mad this application and state the,the aMve information is
correct. I agree to comply with all city and county ordinances and state laws relating to
buildingeoreswction, and hcmhyauthohm mince annees ofthis city toenterupon the
abovemantioned property for inspection p rrpssca
(We) agree ro save, indemnify and keep harmless the City of Cupertino) egainst
liabilities,judgments. costs and expenses which may in any way seem, against said City
consequencein of the granting of this permit.
APPLICANT U DP,RSTAN S A COMPLY WITH ALL NON -POINT
SO ,G ATI S. 0
Ole
WATER SYSTENIGREATING
SOILS FF.Ii 1
WATER SERVICE
PAID
Dae Receipt#
NEW RESIDENTIAL PLMII. SQ. LIT.
TOTAL:
BUILDING f :.E
QTY. MECHANICAL PERMIT FEE
SEISMIC
PERMITISSUANCE
ELECIRI FEB
7J ALTER OR ADD TO MITCH,
PLUMBING -"
AIH HANDLING UNIT (TO I(1,IXX)CI>M1
SIFFHANICAL FE:
AIR HANDLING UNIT (OVER 18,000CFM)
CONSTRUCTION TAX
ngnmurto Applicnm ontr' or Dute
HA UOUS MATERIALS DISCLOSURE
Will the applicar or future building resultant store or handle hiardom material
as defied by the Cupertino Municipal Cade, Chapter 9.12, and the I health and Safety
Cole, Section 25532(a)]
E3 yet; ❑No
Will the applicant or future building occupant use equipment or devices which
emit Initiations air contaminants asJcEned by the Bay Area Air Quality Management
ITattract?
❑Yea E] No
I have read the haallous mamdaLs mummer ems antler Chapter 6AS nftbc Calm
Moria Health & Safety Calc, Sections 25585, 2.5533 and 25534. I understand that if the
building does not currently have a tentm, that it is my respm.sihility m notify the occupant
of the oyuirermtns which mint be met prim to issuance of a Cenificam ur Occupancy.
EXHAUST HOOD fW/Dl1C'i)
HOUSING MITIGATION FE.
HEATING UNIT GTO 100,001) BTU)
HEATING UNIT (OVER 100,088 BTU)
PAID
Date Receipt #
VENT] LATION PAN IS INGLE RESIDE
BOILER- COMP OHP OR IW,gO BTU)
TOTAL.
BOILER- COMP (OVER I fklpo9 BT U)
AIRCONDITIONER
ISSUANCE. DATE
ISSUED BY: 1 V -✓ "T
NEW RITSIDENTIAI. MECiI, SQ. PF.
i7
- L �
Ow
Owner or authorized agent Date
OFFICE