S 1955APPUCANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELNC'1'RICAL Pii ITNO.
BUILDING DIVISION APPLICATION/PERMIT ___,._ PLUMBING -MECHANICAL � 19 5 5
12-4-9 1.1Zy Mor pR•
OWNER'S NAME: PHONE:
(KD2Yff"ll
DAY (D PrQ&Jilp Q Q G --4.9% I D Consultant Feet, Paid by Applicant (Initial)
1 hereby affirm that I um licensed under provisions of Chapter 9 (commencing
wllh Section 70aaU of Division3 of the Business and Pndessimix Code, and Iny license is
in full force and effect.
License Class Lic.p
ARCHITECTS DECLARATION
I understand my plans %hall nit used as public records
Licensed Ponfesrional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contruunr'% License Law for the
following reason. (Section 7031.5. Business and Professions Code. Any city or county
which requires a permit to conamet, alma, improve, demolish, or repair any nmcame
prior to its issuance, also requites the applicant for such permit to file u signed statement
Real he is licensed pursuant to the provisions of the Contractor's Ince re I.aw' (Chapter 9
(commencing with Section 7000) of Division 3 of the Bu%ineas and P ofesaiom Cattle) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500),
O I, as owner of the pmpeny, or my employees with wages as their sole compensation,
will do the work, and the sanctum is not intended in offend for sale (Sec. 7144, Business'
and Professions Code: The Conramfn License Law does not apply to an owner of
progeny who builds an improves thereon, and who does such work himself or through
his own employee%, provided tam such improvements um not intended or offered for
sale. IL however. the building or improvement is sold within one year of completion, the
mvmcr-bmkkr will have the burden of proving that he did not build or improve for pur-
po a Ifwia2
❑ I, as owner of the pobisi am exclusively contracting with licensed contractors et
onswm the project (Site. ]OWL Buxiness and Professions Cede:) The Cnntmc,o/s LI -
«me Law does not apply to an owner of property who builds or improves (hereon, and QTY,
who contracts for such projects w ith a contmemr(s) licensed pursuant to the Contractor's
License Low.
❑ 1 am exempt under Sec. . B & P C for this mason
Owner Data
WOR KERS COMPENSATION DECLARATION
1 hereby a1Rrm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenificam of Consent to self-inxure for Wmwr`.%ComP.m
salion, as provided for by Section 37M of the Labor Code, for the performance of the Q
work for which this patent is issued. O
❑ 1 have and will maintain Worker's Compensation Insurance. as required by Section
37M of,he Labor Cede, for One performance of Inc work for which This permit is issued.
My Worker's Compensation Insurance owner and Policy number am:
Carrier: Policy No.:
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section aced not becompleted if the Tenni, is (mane hundred dollars ($Iq))
or
I rectify that in the performance ofthe work for which this Tenni, is issued, l shall
no, employ any Tenon in any manner so u, become sobjem m the Workers^ Compen-
Oz %alio. Laws of Colifomia. Date
z� Appli� —%
tti c NCI*ICL• AP ICI'L ANI. If, of er ma Ieme o mp,mn, you "should
a' become subject to the Workers Compensation provisions of the Labor Code, you mm,
LLI forthwith comply with such pmvisiom or Nis peon shall he deemed winter
0
U z CONSTRUCTION LENDING AGENCYagecy
V L for. hafh ad, permit
isacd(Sm. onlendingagency for the perlimnance of
0 i-+ ,cedar', for which this Tomtit is issued (Sec. JON], Cir. CJ
Q U Lender's Name
r Lk7 Lender's Address
1" 1 certify that I ply with
ll ciapplication and stem cos the statre wn terming
is
h
counsel. 1 agree to comply wilM1 all city and county ordinances and nate laws rda,ing m QTY.
U Z n�itdins.rn.%wnimn, oma nereqambndae reprexenwbreamnn;%drymemer noon m.
ratcoe-meminned property f,rimpenion purposes.
(We) agree in mve, indemnify and keep h bmalco ,he City of Ca a mina against
Iiabidbo,,mdgmenas, arse and expanses which,nay in any way accme agrool sail City
in m orspo me of the graming of this permit.
APPLICANT UNDERSTANDS ASG WILT. COMPLY WITIM L ON -POINT'
SOURCE REGULATIONS. // i / i� _ /1
HAZARDOUS MAI'ERIAI,S IIISCLOS(JR[3
Will the OFF]knot or ratio building occupant nam nr fruit. h ... aous mmcrial
to, defined by the Cupertino Municipal Code, Charter 9.12, and the Health and Safety
Code, Serono 25532(a0?
El Yes ElNo
Will the ap,devnt or future building occupant age equipment ter devices which
emit arrardous air conmminants is defined by the no, Arca Air Qnably shut . . .......
District1
(_1 ye, E] No
I have rend the hat urdota mnlerinlx mquine oil. ander Chuptm fi.rout theCat-
fnmla Health & Safety Cnde, Socuous 255115, 2593 and 25534. 1 undc,ntend that if the
huilding docs nal m,mcar y have Or lemn61hn1 it May, v.pnnsability m notify the mcnp,tnt
of the mut imments which must fie mat prior In isxnunce of a Cron ream of (Odds nay.
ELECTRIC PERMIT I FEE
FERMI T ISSUANCE
APPLIANCES - RESIDENT AL
PANELS
UP TO 201 AMPS
SIGNS ELECTRICAL •
SPECIAL CIRCEII17M ISC.
'TEMP. M at FR OR P0I.I3 INST. sd
POWER DEVICES
SWIMMING P(A)L ELECTRIC
OUI'LIifS -SWI I CHES - FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
/— ` V
° 1 Mr
JOB DESCRIPTION
RESIDENTIAL
OSFDWL
D KITCHEN REMODEL.
,y ADDITION
[IPLUMBING RE -PIPE
LJM UI.TI-UNIT
ElSTRUCTURAL
DRAINS -11.00R, ROOT. AREA, CONI(.
MODIFICATION
O INTERIOR
OCHIMNEY REPAIR
IMPROVEMENT
[D SWIMMING POOLS
O BATH REMODEL REPAIR D DEMOLITION
OOTHER
GAS -13A. SYS'TE'M-OVHR 4 (EA)
COMMERCIAL•
�0^41H:WBLDG/ADDITION ODEMOLITION
LITFNANT F1 FOOD SERVICE
IMPROVEMENT
ClarHER
SQ, FT. FLOOR AREA
PLUMBING PERMIT
FEE
PERMIT ISSUANCE I O
ALTER -DRAIN&VENO' -WAIIiR(EA)
VALUATION -
/^ D Q V
BACK FLOW PROECT. DEVICE
DRAINS -11.00R, ROOT. AREA, CONI(.
STORIES
TYPE C(
FIXTURES -PHR TRAP
GAS -EA. SYSI CM -I INC. 411ururTS
OCC. GROUP
GAS -13A. SYS'TE'M-OVHR 4 (EA)
GREASI%INUUSTRI. WASTE INTERCEPTOR
BUIhPING IIIVISION (EES
GREASETRAP
PI.ANCHECK IEE 2
SEWER - SANITARY - STORM HA. 2011'T.
ENERGY FEE
WATER METER W/VEN'I11J.11MR
GRADING IEE
WATER SYSTEM/ BEA'T'ING
SOILS PHG
WATER SERVICE
PAID
Date R..eim x
NEW RI:SIDEN1'IALPI.1,111. SQ. Pp
TOTAL:
AL
r
BUILDING PEE
ST:1 !MIC -ECA �
M17CHANICALPI3RMIT FEE
PrRMITISSIJANCI:
ELECTRIC1113E
MECHANICALITE
�I q
AIAHRORADD'IOMECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,000CFM7
C NS'I'Rt1CPR1N:TA%,�
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO Inform it'I GO
HEATING UNIT EVER IIAI,ddp HTIH
PAID
V17N'I'ILATION PAN (SINGLE RI?S1D)
[)are Receipt x
BOILER -COMP (3HP OR I00,0x) IT I'U)
BOILER - COME pIVHR 1011.0410 111
AIR CONDO I'IONI IR
ISSUANCE DATE
?'
NEW RESIDENTIAL MIiCII. SQPI'.
Owner or aathn't.0 agent Data I I E-A'A1-I 1 1-1 Ir ISSUEBBY:
$ISQ. IT.