00010158APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
IILDINGpUUN�/ I\r
/ CONTACT PHONE: - - -
` ❑ Consultant Fres Paid by Applicant (Initial)
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LICENSED CONTRACT URS DECLARAI]ON
of Chapter 9 (emnendn
1 fi-th, affirm Dat 1 am Iutowd under provisions m p g
with Section 7000) of Division fthe Business and Profasias Co e. anJm is nw
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infail c Classed elTecr- b
Liccnsc Class Lich
Date Cnmrucmr
ITECTS DECLARATION
ee
1 understand my plans shall Ire used as public ords
QTY ELECTRIC PERMIT
P'RMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 210 AMPS
(-�F•W
tY IY G
X 3 L U
all LL y
F LL'�g'
Licensed Pmfeasiun.I
OWNEN.BUILDER DECLARATION
I hereby offim+ that I am exmpt efrom the Contractor's License Law for the
following reason. (Section 7031.5. B -mins and Professions C de: Any city or county
which requires a Permit to Conswct. alter, improve, demolish, or repair any structure
priono its issuance. also requires the applicunl for sucM1 pero+iuo Hleuaigncd.ua¢•ritenl
that he is licensedpursuanttotheproviaionsoftheContractorsLicenselaw(Chapter9
201-1000AMPS
OVER II%X1AMP5
SIGNS ELECT RICA].
SPIiCIAL. CIRCUIT/MISC.
E] SWIMMING POOLS
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(commencing with Section7(XXB of Divlsom 3 of the Business and Professions Cade) or
that he it exempt therefrom and the basis for the alleged exemption. Any violation of
Sectinn 7031.5 by any applicant for a permit subjects the applicant to a civil penallynl
no inue than Bvc hundred dollars ($500)
I. as owner f the property. or my employees with wages as their sole compensation.
will du thework.andihcsrucmelx not intended uroffered forsalc(Sec. 7044. Business
and Professions Cure Me Contractor's Lima law does not apply m un owner nl
property who buds or Lnproves thererm, vod who dos such work himself or through
Win own employees• provided that mch imMovememx ate not intended of offered for
TEMP, M FTER OR POLE INS' T.
POWER DEVICES
SWIMMING POOL I!LEGTRIG
011'D.EI'S-$WI'1CIIF_S-FIX •S
NEW RF-SIDENT1AL ELECHR FT
sale. 11, however. the building or hnprovemont is sold within one year To cotnplctian, the
enbuilder will have the burden of proving that he slid nm Wild or improve for punt
'f(ITAI.:
love.1 sem).
Fl I, an owner of the pmpeny, am exclusively contracting with licensed contractors
om uct Ne project (Sm.7044. Business and Professions Coni The Contractor's Li.
se Law dons nm apply tnnn owner of property who builds or improves therem, and
QTY PLUMBING PERMIT
who contracts for such projee s with a contacmr(s) licensed pursuant it) the Contractor's
PERMITISSUANCE
License law'.
1 am exempt under Sec. . B B P C for this reason
ALTER -DRAIN h VENT- WATER (EA)
WORKER'S COMPENSATION DECLARATION
BACK FLAW PRUIEC1. DEVICE
�wner
1 hereby following ns:
under penalty of perjuryone ofthefnsure for docker
andwaffirm
s
Worker's Compere
Clhave poomel finr byineCion 370e of the LabrCod.for the
s lino, an provided for by Scotian 370(1 of the Lunar Cade, for the performance of the
vnrI r which this Permit is issued
DRAINS FLOOR, ROOF, AREA. COND.
FIX'I UNIT-PF:R'1'RAP
have and will maintain WnrWes Curnpensminn Insunmce.ns required by Section
37Wnfthcla nCMc'hsr tM1e lcd'onnanc<ofthe work for wM1ieh tIft perm}�is sued.
GAS -IiA. SYSI'IiM-I IN0.40U'FLEI5
GAS-EA.SVSTIIM-OVER4(GA)
My Werke' n+pr nu curricrut Policy al/)C
Carries Policy Nn.: GY( J
GRF.ASIVINDUST'RL WASTE INTERCEPTOR
CEho if: CATS UP rx F- 1'HON FROM WORKERS'
COMPENSATION INSURANCE,
GREASETRAP
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0his.s-tion need nut rte completed lfthc pemtil is forme hundred dollars 1 S110)
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I mmy that in the performance ofthe work for which this permit is issued. I shall
not employ any person in any runner no as to become subject to the Workers' Comp te-
motion Laws or Ciducamia. Dale
Applicant
NOTICE TO APPLICANT: If, after raking this Certificem of Exemption. you should
bottene subject y in al Workers pr Compensm is ernit hal of the labor Cudc you cons
forthwith comply withsucM1 provisions .,,his permiuhallWcreated revoked.
CONSTRUCTION LENDING AGENCY
Thereby affirm that there is arnnamctinn lending agency lot (lie pedonnana of
the wok for which this permit is issued(SeeNNO, Ci¢C.)
Name
SEWER - SANITARY -S'IYIRM EA. 200 FE
WATER HEATER W/VENT/ELECIR
WATER SYSTEM/IRVATING
WATER SERVICE
NEW RESIDENTIAL PLMII. SQ. 14
TOTAL:
I adder's Address
QTY. MECHANICAL PERMIT
minty that 1 have mad this application and state that the above information is
comer, I agree ,,+comply wi0:dl city and county ondinunms and state laws eluting w
buildiogconswerion. and hereby outhodee reprewmatives of this city toenmr upon the
I+ILRMI'I ISSUANCE
above-mentioned property for inspection purpows.
(We) agree to save, indemnify and keep harmlea the City of Cupertino against
liabilities.judgmems. nota and Cxpneen whialr may In anywayacemcagaitntwid ChY
ALI ER OR ADD' 10 MECH.
+acqucnce of the graming of this .it.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR I IANDLING UNIT (1 0 10,000 CPM)
SOURCE�
V/ - P&
AIR HANDLING UNIT(OVER 10,(XX)CVM)
EXHAUST 14001)(WIDUCT)
Signature of aaor Date
RDI S MAT17RIALS DISCLOSURE
Will the npplicam or furore building oneupunumm or handle hmardas mamrial
HEAPING UNIT (TO IW.IXO B'fU)
HEAPING UNIT (OVER I W.(XX) BTU)
as dd cal by the Cupertino Municipal Code. Chapter 9. 12, and the Health and Safety
Calc, Section 25532m)7
C)Yen o
lllp
Will the applicant or future building mcepaot use equipmeJdevice—hiches which
cmil hamedous air and not on ax defined by the Bay Area Air QnagementDistrict
VENTILATION FAN (SINGLE REM U)
BOILIE-COMPf3HP OR 100,010 BTU)
BOILER- COMP(OVER 100,1X0 BTU)
Yes �/��yu
AIR CONUITIONEN
1 have read 0+e hn, dnwsu+weriuls"'Doic end, under Chapf the Cal
NEW RESIDENTIAL. MITCH. SQ. FT.
fomid Hcul •@ Safety Code. Sections 25505. 25533 and 255Y1. 1 uthat if the
WitJingJ mormormlyhim.team.thato is my mspovsibllitl Imvup:ntnon
to which met prinrm lswanm nraeertihmey.Owner
TOTAL:
lir agent ate
OFFICE
FEE
FEE
0
BUILDING PERMIT INFO
3LDG ELECT I'LL UM(1y MSCI
❑ ❑ LJ ❑
JOB DESCRIPTION
RESIDENTIAL,
C SFVWL
C KITCHEN REMODEL
❑ADDITION
C PLUMBING RE PIPE
C MULTI -UNIT
CSl'RUCTURAL
MODIFICATION
C INTERIOR
LD CHIMNEY REPAIR
IMPROVEMENT
E] SWIMMING POOLS
C BATH REMODEL`REPAIR C DEMOLITION
C OTHER
COMMERCIAL
❑NEW BLDG/ADDITION
C TENANT
IMPROVEMENT
C OTHER T
SQ, FT. FLOOR AREA
C DEMOLITION
C FOOD SERVICE
40
BUILDING DIVISION ITE
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dam RdmaP1#
BUILDING FEE =
FEE SEISMICFIE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL. FEE
CONS'FRUCFION TAX
HOUSING MIT IGA PION FEE
PAID
Date Receipt#
ISSUED
031
ISSUANCE DATE
2-Z-?,L-oZ)