C 0419 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY V T
CITY OF CUPERTINO BUILDING. ELRCI'RICAL P13RMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL 7SANITARY
IIUIhDING I'x(IJIUYI' IDRN'rIFICA'I'IUN
NO. APPLICATION SUBMI'TT'AL DNIE.
BUILDING ADDRESS
&8 P(Z\rnQoSE W A CUP6QTIIJO CA I�
OWNF'S NAME PHONE,: CONTRACTOR' NAME: LIC No. CONTROI.g
-095
RCHTTECiENGINCEIE LIC NO'. ADDRESS: �r
Lis In 0 w 1 J, � lY1P
_..,..._ BUILDING PERMITINFO
LICENSED CONTRACTORS DECLARATION
1 hereby a1Rmt Thal Iver licensd under pr..visinns of Chapter 9 (commencing
x with Salion7000) of Division J of the Bitimiess and Punfesions CnJe, and my licema is
y2 in full force and effect. 11 �1CZ 7
JU License C- I,ic.g _-JL T
GaDate. �assl[I� _Commeva—
N ARCHITECI'S DECLARATION
n Z I understand my plans shall he used as public records
WLiecascl Professional
g
OWNER -
Wt
DEChARA'DON
W t I hereby alLna that I m.. exump, from the Cominclor's License Law for the
L U following rears..... (Section 71131.5, ansines and Professions Code: Any city or county
Oy which requires a permit In canalorel. alfa, I"'Prove, Demolish, or repair any'metal
Prins no its isvummq nl'u 1111-11- the applicant pa uucn perm.. m file u signed sm entere
Q�,Mn he is llmnsel pummom to the provisions at he Cournemr's Liccnse Law (Chapter 9
(caa....mncing with Seri i7000)uf Division 3 al he Braes and Profcsinns Code)or
that he is excmp, Ihembour not d htia
e basin Thr the alleged cxentplion. Any vinlan of
_
Section 7031 by any appftca..l far a IMair xtbj.v he applicant to a c'tdd penally of
"not norm than live hundred dollars ($51H1).
=Q m ❑ L as owner of the property, or my emplayms with wages as their cole comper,aron,
F.willdothe work.andth, structure is notarendedoroffamd forsale(Sec. IIW4, Basins
3� 0 and Pndessinas Ctde:'1Te Cammetnr'.. License Law does not apply to an owner of
property who builds or improves ihemon, and whir does such work himself err through
his own employees, provided that such improvements um not intended or offered for
role. If. however, the building a improvement is stud within one year of completion, the
onster-builder will have the burden of proving than he did not build or improve far pur-
po a of sale.).
L as owner of the Properly, ant exclusively contracting with licensed contractors m
construe the project (Sec. IIIc, Business and Professions Code .I The Contractors L`
mm,e Law does not apply m an owner of progeny who builds or improvesr them yrPpMMm!Int
a d
who contracts farsuch pmjmts with a communist licensed pursmmus th W is
Limnsc Law.
I am cecmp, We, See .B&PC far Irt5pn
❑ CnnSultant Fees Paid by Applicant (Initial)
BLDG ELECT
❑ ❑
PLUME INSECTS
❑
QTY ELCCFRIC PERMIT EEC
JOB DESCRIPTION
RESIDENTIAL,
❑SEDWL ❑ KITCHEN REMODEL
[]ADDITION [I PLUMPING RE-PIPH
❑MULTI -UNIT ❑SIBUCIURAL
MODIFICATION
❑INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
❑BATH RE EIJREPAIR ElDFMOI,I'IION
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANT -IS
UPT0200AMPS
201-1(XX)AMPS
OVER IINS AMPS
SIGNS ELLC'I'RACAL
SPECIAL CIRCU11 /MIS '.
TEMP. M13'i'13R OR I' LI! INS'll
M R IA ,:
❑ NEW BLDGIADDI'I ION
❑'I`FNANT
IMPROVEMENT
❑O'T'HER
Q DEMOLITION
❑FOODSERVICE
POWER DEVIC_
SWIMMIN'DOL Ell TRIC
OUTL' S - SWI ICI113S-It1X"
Dere
net WORKERS COMPENSATION UI!CLARATION
I hereby aff r under Penally of perjury one of the following dcelarations.
FolInavenna will main lain a Cenifimm ot.
f Consent sel6for r workers Co.
mtinn, as provided for by Section 3700 of the Lkr Coal, for the performance of the
work for which This Penni, is issued.
1 have and will maintain Workdv Compensation Insurance. m required by Section
39q) of the LaMn Ode, 1'ar the Ierformunce of the work for which this Permit is issued.
MyWorker, Co iM,mion Insurance c xierand PolicyLfbgIrb 9e. b-3 /yN
CanicUnm [' ErJTI?`I Policy No.: FI Y O W
C13R'rIIgCA'fH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be c nnplet W it the permit is for one hundred dollars H I00)
orle".)
ready IeIna in Ibc lxdinntunce of(lie, work for which this r Panni, it.isucd1shall
nm employ ratty Pc nn In any munµcr st nn,a Mqn� suhjed m the Wnrkerv.' ComPen-
Z nation laws of CJI: if, 1. Date D
zC) Applicant
rr y NO'S SEE 10 APPI.IC '1': 11, alternation, this Cenilicatic al Entrap, r, you should
by heeotis, sabjeo at Lha Worker's Co..iN,setlnn pm ro..... of Ibc Labor Code, you moa
Iakl r�i Iinhwilh cmnply with such pmvlsinnx or this peri, .shall is, deemeJ revoked.
n' CONSTRUCf[ON LENDING AGENCY
UO khereby whichmUhermit i ixamnmmc.ion 11. Civ agencyfonhe perinrmuncc of
Los F Lewud, for which this posit is issued (Sm. 3091 Civ. CJ
O U Lender's Name
} {k7 IEeti
terryAddress
1
a certify that 1 have with
it city and com and sere that ,he d alae information w
UN bonding1agreeieon.comply withallcityand countyordinancesda, sate law srelatinghe QTY.
U Z building mnamninn. and hereby authorize npmscnw,ives nDbis ciy to enter upon the
abuse-niscri Nedp.,,.Yfor inspection purposes.
(We) agree ,o rove. indemnify anti keep harmless the City of Cupertino against
liabilities, judgments. east, and expenses which may in any way accrue against said City
in ronsc, ence of the 8ramir, of this pemtit.
APPLICANT UNDCRS'1'ANDS AND WEI. COMPLY WITH ALL NON -POINT
SiBmmmof 'nnUCon,rectnr - Dam
HA].ARUKIUS MATERIALS DISCLOSURE
Will the applicant or!verse heading umupanl surer nr handle hezallous material
us obfnal by the Cupeninn Municipal Code, Chapter 9.12, and the Health and Safety
CMe. Section 25532(07
❑Yes (:I No
Will the applicant or future hailding teeupnnt use equipnretn nr devices which
Imit hazardous it cnalmainanls us debuld by She Buy Area Air Quality Management
ALIA04, FRAIN&VENT -WATER IRA)
BACK FLOW PR( ECT. DEVIC :
DRAINS- iA. COND.
FIXTURES -1' THAI'
GAS -13A. SYSTEM
GAS - EA. SYSI'Iim-OVliR d IIS
GREASFJINDUSTRI, WAST' N'ITRCIiI'IT)R
GREASE'I RAI'
SEWER - SAN] 'i'A - SI URM HA. 2(X1 Ir I'.
WAI'ERIIHAI'. W/VEs I'/I:I.I;CI'R
WATERS , iEmOREAI'ING
WAS SERVICE
;W RESIDEM'IALPLMH. SQ. PI'.
TUTAI.
MECHANICAL PERMIT'
PERMIT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT LTO 10.000 CFM) -
AIR HANDLING UNIT(OVER 10,000 CFMI
EXHAUST HOOD(WIDUCD
HEATING UNIT (TO I W.00) BTU)
HEATING UNIT (OVER I01.0001 Ill US
VENTH AT ION I7AN (SINGLE RESID)
IfQILBR -COME (311P OH Iba"'I 011'I'U)
listnd'I BOILER-COMP(OV13k ITN) S,II'llJl
dyes No
AIR CONDITIONER
I Inlvc rad Lha nuandoux aniaiulx reyuiretncros under Chain, b.95 of the Cali-
la'niu I loalth & SURIy Cute, Serious 25505, 25533 and 255y4, l understand that if the N13W RI!SIDHN'IIAI. MFC1I. SQ, Irl�
nuilJing droll not cnmully huvc a tnnnnL dhoti, i.v my rcepnndhitity to notify the ocntpaid
of the rcquitmnere, whialt ain't P, tact prior 03.....E ce of it Certificate of Occupattsy.
'IOTAI.
Owner or authadma agora Dutc
OFFICE
FT
EEE IIT' MAY 19
STORIES
I - BUILDING DIVISION FEES
PLANCHECK PEE
ENERGY FEE
GRADING FEE
SOILS FEF
AIN
Receipt p
BUILDING FEE
FFE /� SEISMIC FEE
. ELLCTRIC FF.E
PLUMBING FEE I
MECHANICAL FEE y- / • / v
CONSTRUCTION TAX
HOUSING MITIGAHQN FTE
PAID
I OTAL: