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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII,DING - RLEC'1'RICAI.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICA]
BUILDING PBOJECTIDENTIFIC.
RUILDINGADDRESS: 11 t—
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: / Qt- I v Ic�_, V f 77-)_o6 JI ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hemby chino that I am licensed uMe, proemom of Chapter 9 (rmnmeacm,
with Section 7") of Division 3 of the business and Professions Code. and my license is
QTY
PERMIT ISSUANCE
in fullforceand X
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Licenc Class
Date —$��cNa
ARCHITECTS DECLARATION
1 ) Ifthe Labor Cade, for the performance ofthc work for which this Permit is issue.
My workers Cape tion In rand Policy numhc[an;,P7
Cartier 5 rA-%�. �-'wkr"'v reit YnlicY No.: OO1l{{9
CERTIFICATE OV E INN PROM WORKERS'
Ire "sun Y plans sh 11 h cItopublic re ands
61-
I.cx 'mfcsninnul
OWNER -IG) 11 :.D . .A RATION
ATION INSURANCE
COB,
1 hereby afftnn that 1 am exempt Irom the Contractors License Law for the
fallowing mason. (Section 9031.5, Business and Professions Code Any city or aunty
which requires a permit to construct. alter, improve, demolish, or repair any shuchim
prior it, its issuance, also exculms the applicant for such Permit to file a signed statement
that he is licensed pursuant o the pareviens of the Contractors License Taw (Chapter 9
(commencing with Section 900101 of Division 3 of the Business and Professions GNe)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to acivil Penalty of
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not mote than Fee hundred dollars (550(11.
❑ Las owner ofthe properi or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or oRcred for sale(See 7094'Business
anti Prodessians Code: The contractor'sLirenxe Law does net apply m in owner of
Po'I arty who mildc a improves duacon, i I who Jnes auch work himecll nn111nu0h
I... own empinyccs, provide that such impowmncros um not imendcd nr offered Pert
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beton subject to the Worker's Compensation provisions of the Labor Cafe, you must
falrahh comply with such pmvisionrorthis pcnnil h.11 the deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby afhnn thio there is - Imetrartiors309ending agency for perfonnance of
me work for which this permit is issued (Ser. AMY(. Co, CJ
Lenders Name
soca IL however, me building or improvenmm N sold within one year of completion, the
ownromildirr will base the burden of proving that he did not build or improve for for,
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pose of arm),
I. as owner of the pmpeay, am excli ancLy contracting with licensed emantcum in
constsun the pmjeat (Sec. 961d, Rusinos end Profesmaris Code:) The Cmurfoom'e Li -
cruse Law does not apply tocon owner ofpmpeny who builds or improves theaon. andQTY.
who wrapursuant ntces for such projects with a come ntons) licensed pursuano the Contractors
QTY,
License law.
Earn exempt under Sec. . B & PC for his rt
ELECTRIC PERMIT
FEE
PERMIT ISSUANCE
E
APPLIANCES - RESIDENTIAL
PANELS
UPTO2W AMPS
1 ) Ifthe Labor Cade, for the performance ofthc work for which this Permit is issue.
My workers Cape tion In rand Policy numhc[an;,P7
Cartier 5 rA-%�. �-'wkr"'v reit YnlicY No.: OO1l{{9
CERTIFICATE OV E INN PROM WORKERS'
SIGNS ELECTRICAL IRCU
SPECIAL CITIMISC.
TEMP. METER OR POLI: INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - S W ITCH ES - FI%1'U RES
NEW RESIDENTIAL ELECI'R SQ
Will the applicant or futurt Molding occupant Stare or handle hazardous material
,is drained by the Cupertino Municipal Code. Chapter 9.12. and the Health and Su@ty
Cale, Section 25532(1)!
E]Yes JSINa
Will the apo cam nr krone hn'dding nccnpunt ase uyu t, ram or dcviau which
6n( huearders air conw'ninuma ns (dined by the Hay Arca Air Quality M:megatent
Uisricl7 , /lo
Yes iR�N
I have reed the fe,ananus materials ramusama is under Chapter 6.95 of the Cali-
fmnia Health & Safety Code, Scetinns 25505. 25533 and 25514 I undasmoJ that a the
huildine does not tonin, have a tenant, that it is my responsihilay u, notify the occupant
PLUMBING PERMIT
ALTP DR & Vf - WAI FR IBA)
BACK chow rR ' �' 'las
DRAINS - FIA R( i": HA.COND.
FI%TURES-PER'IRA /
GAS -EA. SYSTEM -1 INC. q O"AU'S
GAS - EA. SYSTEM OVER q (EA)
GREASF/W DUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER BEATER WNEN'TAILEiCTR
WATER SYSTE WE REAPING
WATER SERVICE
NEW RESIDE UAL PLMB, SQ. FT.
MECHANICAL PERMIT
PER M IT ISSUANCE
ALTER OR ADD'1'0 MECII. 12
AIR HANDLING UNI'P(101410X1 CFM)
AIR HANDLING UNIT (OVER Ih.000 CPM)
EXHAUST HO(A)(WIDUC I
HEATING UNIT (TO 100.000 B"f U)
IBATING UNIT (OVER I010m) 131 BE
VENTILATION VAN (SINGLE RE?SID)
BOILER -COMP 0HP OR RgUHM) li'1'U)
BOILER - COMP(OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. ET.
OFFICE
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❑ 22 -(72 -
BUILDING
Z5,2rBUILDING PERMIT INTO
BLDG F,LECT 1`LIIMB MfECH CH
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JOB DESCRIPTION
RESIDENTIAL;
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBINGRE-PIPE
GifGcANT ❑ FOOD SERVICE
IMPROV17MENT
❑ O nUiR
SQ. FT.FLOORAREA I $ISQ. PP.
FEIi3I(Ll3 Sf_
/:S70 000
STORE I 'I
_? 1'"K" Zb
BUILDING DIVISION PEES
PLANCHECK FEE /� O
ENERGY FI� C �_-LQ
AID
Receipt p
TOTAL:
Ir BUILD( -FEE
FEE SEISKb FF,. III
liLiA tCFili
P 1 1 NO FIE
N11'CI NICAL HE
CON. RUCTION TAX
HOUSL ' MITIGATION FEE
PAID
Dare Rcceipl p
T(IALIr--1�-)
ISSUANCE LATE
S-- 21-- 9C1./y
1D BY: �g
Owner Date
WORKER'S COMPEiNSAOON DECLARATION
.
I hcrchy affirm under pcaAty or perjury one of the following dallarmmrss.
I have rod will minimum u Ctmfiwte of Cntsam m selfinsure fur Worker's Contic n-
smlon, as pre idod for by Section 3700 rd the lahor Code, for the perfonnuncc of the
work for which this permit is I'lard.
" 1 havc and will maintain Worker's Compcumion Immorce, as required by lection
1 ) Ifthe Labor Cade, for the performance ofthc work for which this Permit is issue.
My workers Cape tion In rand Policy numhc[an;,P7
Cartier 5 rA-%�. �-'wkr"'v reit YnlicY No.: OO1l{{9
CERTIFICATE OV E INN PROM WORKERS'
ATION INSURANCE
COB,
evaNSATION
(This seainn need not be annpineJ it the penniYn !crone hundred dollars (5100)
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or Icsu.)
Icerify that inihe performance nfthc workfor which this Permit is issued, lshall
not employany person' any nun 9.bjectiotheW mrVCoot@m-
'inion Lnwsaf Callforttw.LLtc 1 l^^��
O
Appfieanl
NOI'ICI: TO APPLICANT: 11: after tanking this Cel me of Exemption, yoa.should
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beton subject to the Worker's Compensation provisions of the Labor Cafe, you must
falrahh comply with such pmvisionrorthis pcnnil h.11 the deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby afhnn thio there is - Imetrartiors309ending agency for perfonnance of
me work for which this permit is issued (Ser. AMY(. Co, CJ
Lenders Name
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Lcoder'a Address
I cenify that 1 have mud this application and state that ale allote imomtmirn ix
conal. I rgtce m comply with all city and county n dammed and Mare laws riming it,
handing construction. and hereby amhnriee rcpmvcnmrives of this city n, enter upon the
alwve.roau mrd lropemy Inc Insprehoul Tunnee
(We) uEi. to sue, indemnity anti keep hunnlesahe City of Cupenlnn ugalno
liabilitio'.judgments, cons and expemes which nmy in any way rectae agmen said City
QTY,
eqncc of the granting'If 'his panic
in.... uc
APPLICANT UNDERSTANDS ANI) WILL COMPLY W11H ALL NON -POI N'I'
SOURCE RF,GULA'1'IONS.
Will the applicant or futurt Molding occupant Stare or handle hazardous material
,is drained by the Cupertino Municipal Code. Chapter 9.12. and the Health and Su@ty
Cale, Section 25532(1)!
E]Yes JSINa
Will the apo cam nr krone hn'dding nccnpunt ase uyu t, ram or dcviau which
6n( huearders air conw'ninuma ns (dined by the Hay Arca Air Quality M:megatent
Uisricl7 , /lo
Yes iR�N
I have reed the fe,ananus materials ramusama is under Chapter 6.95 of the Cali-
fmnia Health & Safety Code, Scetinns 25505. 25533 and 25514 I undasmoJ that a the
huildine does not tonin, have a tenant, that it is my responsihilay u, notify the occupant
PLUMBING PERMIT
ALTP DR & Vf - WAI FR IBA)
BACK chow rR ' �' 'las
DRAINS - FIA R( i": HA.COND.
FI%TURES-PER'IRA /
GAS -EA. SYSTEM -1 INC. q O"AU'S
GAS - EA. SYSTEM OVER q (EA)
GREASF/W DUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER BEATER WNEN'TAILEiCTR
WATER SYSTE WE REAPING
WATER SERVICE
NEW RESIDE UAL PLMB, SQ. FT.
MECHANICAL PERMIT
PER M IT ISSUANCE
ALTER OR ADD'1'0 MECII. 12
AIR HANDLING UNI'P(101410X1 CFM)
AIR HANDLING UNIT (OVER Ih.000 CPM)
EXHAUST HO(A)(WIDUC I
HEATING UNIT (TO 100.000 B"f U)
IBATING UNIT (OVER I010m) 131 BE
VENTILATION VAN (SINGLE RE?SID)
BOILER -COMP 0HP OR RgUHM) li'1'U)
BOILER - COMP(OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. ET.
OFFICE
2Z
❑ 22 -(72 -
BUILDING
Z5,2rBUILDING PERMIT INTO
BLDG F,LECT 1`LIIMB MfECH CH
0— u
JOB DESCRIPTION
RESIDENTIAL;
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION ❑PLUMBINGRE-PIPE
GifGcANT ❑ FOOD SERVICE
IMPROV17MENT
❑ O nUiR
SQ. FT.FLOORAREA I $ISQ. PP.
FEIi3I(Ll3 Sf_
/:S70 000
STORE I 'I
_? 1'"K" Zb
BUILDING DIVISION PEES
PLANCHECK FEE /� O
ENERGY FI� C �_-LQ
AID
Receipt p
TOTAL:
Ir BUILD( -FEE
FEE SEISKb FF,. III
liLiA tCFili
P 1 1 NO FIE
N11'CI NICAL HE
CON. RUCTION TAX
HOUSL ' MITIGATION FEE
PAID
Dare Rcceipl p
T(IALIr--1�-)
ISSUANCE LATE
S-- 21-- 9C1./y
1D BY: �g