B 0107APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BuauHNG-f: ECHA IAL rt� 0107 SO7
BUILDING DIVISION APPLICATION/PERMIT rl.uhmmr..131IDENI IFIL 50001 \5 '2,
IIUILDI6G I'ROJI!LT IUBNI'IPIG'1'ION
BUILDINCADDRESS SANITARI'NO. API'LICAI'[ON SUBMIITAI. DAT
10,:; � 2, Va l rel PaVk_1I115
�, ❑ 1 ��(0a
kit BUILDING PERMIT INFO -
ev❑ Consultant Fees Paid by Applicant (Initial) BLDG EuiCl' PLUM
ysy ❑ ❑ ❑
I hereby mf nn that I am Ine,ord ceder provisions of Chapel9 (counteract,
Qd'Z with Sfd1e.20Ngof Division 3nfthe Insinessmd
LicnmPmfessionsS
and myleence is
Ing
in 12176
qb
clfnmaLic.xO
I Qw ).,a Cel... or JQI
NJ, ARCHITECTS DECLARATION
F m Z, 1 xm 'stand my u . allU be ragg as public records
H�E'LLl LiceusN Rolcsvonul
OWNER-BUH.UERD CLARATION
y� Q I hereby nmrin mut I mm exempt from file Contractor's License Law for the
xL O following reason. (Section 7031.5. pastures and 11 fic ,ions Calc: Any city or county
W 3 U. h which requires a Permit to construct. ober, improve. demolish. or repair any structure
F �-�� prior to its issuance, also requires file applicant far such permit o file in signcdseemcm
�y (hal he is llcensal pnssuanrm the pnwwon, of the Comrunor's Uorrsw: Law Winds'9
n1�00 (commencing with Section 7191) of Division 3nfthe lRomessend(toll inn, Code)or
d d e t1 that he is exempt Iherefrnm and the basis for the alleged exemption. Any violation of
„y Sedmn 7031,5 bymry applinmt for a permit sobject, the applicant ,I nmvil pemlty of
ton mom man five hundred dollars (SSW).
=Q O La.ownet of the PropenX of my emploYees with wages as their sole comPenormse.
p.. will rill the work, and the smaiere is not intended or offered for sale (Sec. 7044. Business
W j~ m and Professions Code: The Contmcmr's License Low does not apply to an owner of
C peopeny who build, or improves thereon, and who docs such work himself or through
his awn employees, provided that such improvements .m not amended or offered for
Dole. IL f—ase., the building fir improvement Ix xold within one yea, of completion, the
wnerboilder will have the burden of proving that he did not build or improve for pur-
N of sale.).
O I. a., owner lot be in rlpery, um exclusively contracting wire licenscd mmractors w
acetrill the )reject (Sec 7044, Business .,,itP of .. but, CoE:) Gmaaded
u Low docs not apply its an owner of property who builds or improves 'bureau. add QTY.
who cammets for such projects with a contractors) licenmd Pursuant m the Contractor's
Liccnsa Law.
O 1 an exempt under Sec. . Is A P C fell this remnn
Date r air WORKER'S COM PI?NSAI'I LIN DECI.A RAT ION
1 hereby anion under Penalty of perjury one of the following declardams.
I have and will mommin a Cenificme of Consent to ed1-insure fta Workers Comped-
sminn, us provided I'or by Scctloe 3900 of the Labor Cn ]a, for the performance of the
we far whicb this pcmfit i.s ismed.
1 have anJ will maimain W'ndcr's Compcnsainn Insumnee, as required by Scetion
371.) o1Ihc l.vhor Cnde, for:hc pcdnnnunm of the work for which min pencil is ossa
My Won,
Co: scion ins ensu varier anJ Pnllcyn cher:
Cama: ! Policy No.:
COMPENSATION
OMPIFNSATION INSURANCE
NSURANCE
i fDfi,sccfion Decd nm he camplcted iffhc pcmtit is for onehundfMdnllufs [5100)
or less.)
(canny:hat inthe any mann, of the work for wInch this Permit isersCo shill
not employ any person in any manner as b1 become subject m the Workers Complain
Z scion laws of California. Data
Z0 Apdrealo )
h NOTICE TO APPLICAN'1% 11: aIle, making this CcuiGcum of Exanpeon, you should
(--' berome subject In the Worker's Compencalion provisions of the Inbor Crile, you muM
Wforthwith candy with such pmvi,inm 0, his Permit shall be deemed revoked.
d
,U Z CONSTRUCTION LANDING AGENCY
U Q (hereby affirmthanhem isuctnm
mctinn lendingngagency for the perlirnnanee of
the work for which this permit is issued (See XN7. Civ. C.)
Leeders Name
0 U Lenders Addres
Us
W 1 certify that I have mad this application and state that the above information is
0 convect. I agree to atmply with all oily and curvy,Hammes, still state box, relating to QTs,
L) Z building eonvated n, and hereby..:boom fepownetive, ofthi, city In anter upon 'he
above-mentioned property for inspection purposes.
(We) agree to save. Indeomlly and keep hmmless the City of CuNmmm against
liabilities, judgments, costs and expenses which troy in any way.ceruc against said City
in consequence of thegmafin s
) f.
APPLICANT 11NDIi N AWII //�g/� MPLY WITH.LLL NON -POINT
SOURCE NEO Il1N,' �j
HAZARDOUS boding neAI.S Dm CLO URE
handl
Will the a Canadian
or future Mmu building e, Chaplet
t 9.1ore or huddle Heardous material
us Adincd by :hc Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)'f
,Vats )"�n
Will dm app(isanl or fair,, building oceuPunt use equipment or devices which
tit hovardnus air comeminams as dchned by the Hay Area Air Quality Management
District?
❑ yes
I have red the b rte mma, mr mmol nus under Chapter 695 of the Cali-
fnmia Health A, Safety Cyy¢¢. Sec' 5505.25533 and 25534. 1 understand fund if the
buildinu drlev nm cu:yMf3/11uv sena ,ppa l: is my mspmsibiliry mnotify the cecupam
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
IIP TO 210 AMPS
201-1000AMPS
OVER 100 AMPS
SIGNS HIXCTRICAI,
SPECIALCI UIDMISC.
TIN . BOR VOLE INS'K
POW DE.
SWIM LHLE C
OOI'1 1'1 CUP ;M IIS
NEW RESIDE. A 'LXQ'R SQ FE
PLUMBING PERMPr
PI?RMI f ISSUANCH •
ALTER - DRAIN d VENT- WA'IL
IIACK FLOW PROTECT. DI. ,ICE s
i
DRAINS - FLUOR. ROOF, AREA. C(LNU,
FIX 'I'U RIS- PER 'I'RAI' ♦,
GAS - EA. SYSTEM -I INC.4 OUTI.E'fS
GAS -EA. SYSI HNFOVER 0 (HA)
GREASrANDIISTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY- S'IURM EA. 200 Flt
WAT12R HEAI'IiR WNENTIELECTR
WATER SY11EM PING
WATER SERVICE
NEW RESIDEN'I'1 P.MB. -- SS). IT.
fOPAL.
PERMIT ISSUANCE
ALTER Olt At)[) 10 MECI I.
AIR IIANDLING UNIT LTO 10,000 CPM)
AIR IIANDLING UNIT (OV ER 10,000 Cl M)
EXHAUST HOOD (W/DUCFt
BEATING UNIT (TO 100,E BI U)
HEAPING UNIT (OVER IOU.000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILI!It- COM(' (311POR I W,(XN1 BTU(
BOILER - COMP (OVER IW.000 BTU)
AIR CONDI'I ONER
NEW RESIDENTIAL. MECH, SQ. FT.
TOTAL:
OFFICE
FEE
JOB DESCRIPTION
RESIDENTIAL:
IIIISMIC I'li
❑SFDWL
❑ KI'ICl IEN REMODEL
C1 ADDITION
❑ PLUMBING RI%PIPE
❑MULTI.LJNI'1
❑STRUC URAI.
MODIFICATION
El INTERIOR
❑CHIMNEYREPAIR
IMPROVEMENT
0 SWIMMING IDOLS
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
J; .. to
COMMERCIAL:
❑ NEW BLDGIADDITION ❑DEMOLITION
cy�yfvENANT ❑ FOOD SERVICE
t`I MPROVEMENr
OOTHER
FLOOR AREA
J
PI.ANCHECK
i?NI?RGY I
3
SISO.IT.
IUILDING IT'. /
s
IIIISMIC I'li
If,E.
NH
PAID
Data Rcccipt M
J; .. to
ISSUANCE DAN,
�-/�4-(P9
ISSUED BY. ::S It 0 __57
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