S 0367 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL PERMIT NO. a( 7
BUILDING DIVISION APPLICATIONAIIERMIT PLUMBING - MECHANICAL S . O V 6 1
h. � ..1,Btll],DIN(:PROJI?(IT[Dl[N'riF'ICATION!f, I':, I .'f, _
'it !6-%0VV_S
R'SNAME: PHI( f
�Q.aal¢s- W\%E Ls Citi QS'
CONTACT: nwnu:
�� l�A•�ZkS CIs)34�- bion
LICENSED CONTRACTOR'S DECLARNI ION
I hereby affirm that I am licensed under pawisions of Chapter 9 Rounmencing
QaZ with Section 900h) of oivixint 3 or the Rnsimssamf Pmfcssiom Code, and my license in
Hm °int III finite and once, l rp
Q U U License Class
yZ w Date Commnnr
6 0. ARCHITEC'T'S DECLARA'I'10
F Zn Z 1 undersand my plan, shall he used as public ace its
O—Ez
[-. 4 F' W Licensed Professional
CQ OWNER -BUILDER DECLARATION
¢ 1 ta-uhy off rn that I am exempt from Tho Courrown", License Low, for he
U fnllowing reason. )Section 70315, Business and Professions Code: Any city or county
3 LL i- which requires a Fermi, m construct, alter, improve, demolish, or repair any structure
�ya prior to it issuance, also requires the applicant formch permit to file a signed statement
ilia hcl,lwen ^cd pursuant,thep uskicasof a re Contractor, Lseme Law (Chapter 1)
4�� (commencing wi,hSadmTOW)ofDiswan3.floc Businmsand lkofcsxinnx Cocl
Q. X e fy ran he is exempt therefrom and the basin for me alleged eumpliaa Any conation of
�--y
Section 7031.5 by any applicant for a permitsuhj., the applicmnto a civil penaltyuf
IIrr n mora than Eve hundred dollars ($500).
q dO n1, as owner of the proper,, or my cmployem with wages as their sole cnmpeneion,
22 will do the work. and Re structure is na, intended or offered for sale (See.]IW, Rusiness
Wand ProfeWitim, Code: The Cantrector's License Iain does net apply to an owner of
h property who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such impmvunems are nm Intended or hatred tar
sale. If. la w,,er. the Falling- impoocmmmt is sold within one yam of completion, the
er-milder will have the burden of paving that he did not build or improve for per-
raxe of sato).
❑ L as uwnernf the progeny, am ca clu,ecly anutructing win, licensed onlmct.rs I
consortia ,he project (Sec. 7044, Hoine,x and Pmfcssiom Code.) The Contractor', U.
a case Law does not apply to an owner m property who builds or improves thereon, and
who contracts for such pmjccts with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under So. ,li&P C for this realm,
Owner Dare
• WORKER'S COMPENSATION DECLARATION
I herchy affirm under Penalty of perjury ane .f the fel lowing dr6amlitars
IS t nave and will maintain a Cenificme of Con.ern to self -incur, far Wader's Compen-
sation, as provided for by Satins 3001 of the Labor Code, for the peofi,mrance of the
inn .r which this recruit is issued.
1 have and will mulauin Worker's Compenxntinn Insurance; as require) by Section
3700 of the lath., Code, lout the perfnnnunde ofthe work far w�hh,i�ch this permit i, issued.
My Wa)+rr'scam ammormee career and Policy 4Ar)�1i4•Do \QSZ-I
cari,r: fL�JI(w�caber FROM
WOR O
CERI'110CATIi Olt li IiMPT10N PROM WOk KERS' '
COMPENSATION INSURANCE
(This section aad int to completed Ifthe permit is mnme hundred dollars ($100)
orlessa
I ail, thin in ncpoo. man an fit work farwhiclu suis permit Is ix x..F Isholl
nm nnpl.y any person in any annorsoyynh 46"E'WKn he cornnikcrs'Cnmpen-
Z Ballon Lawn of CaMfol�a' L S 1.
ZO nppf,an, L..C.— -I
o-. r%] NOTICED) APPLICANT: H altar making this Cemfica�'Acmraon, you should
a ; become subjal In the Worker's Cnmtpcnsati.n provisions III the Labor Cola, yen amt
forthwith comply wimstch proves roes r,hi, permit shall M decmedmvoked.
Q
CONSTRUCTION LENDING AGENCY
-X. - I hereby affirms that there is a consuuctlnn lending agency for the performance ill'
the work for whichdti..roc.!i cd)Sec. 3WO, Cie C.)
O f,Lender', Name V V suF
Lenders AAdmsx
1 reddy mat 1 biose read suis application mod slat. mol the chose Informmian I,
r y correct 1 agree to comply win all city antl com y ordinances and state laws relating It,
fJ Z building construction, and hereby authorize mrosenetives of this city to enter upon the
abuse -mentioned property for inspection purposes.
(We) agree m save, it ltmai ly and keep htumless the City of Cupertino a .tubt
liabilities, judgments. costs and expenses which )nay in any way accede agai mt said City'
in consequence of the granting off permit
APPLICANT UNDER S NO WILLY WITH ALI. NON -POINT
SOURCE RF,GULAT INR.
s 7-3o.R-7
Signature of APPlicanV omme Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or f num building occupart,store or handle hmarsbas aa,erial
as defined by the Cupertino Municipal Code, Chapter 9.12, caul the Hleahh and Safety
Cade, Section 25532(a):'
❑Yes Nn
Will the applicant or future building occupant use equipment or devices which
mit haandouc air contaminants as defined by the Ray Area Air Quality Management
DIA, . it[ 7
1 have read the ha tardus materials no draments under Chapter 6.95 of the Cah-
form Ileahh & Safety Code, Sections505, 25533 5534. 1 mormtund that if the
i
building Jcex not currently hgveumnamt nmhi, my po sihllhyU mAdyne.cenpent
NAME:
❑ Consultant Fees Paid by Applicant (Initial) _
L'LECTRIC PERMIT',;r'�r, I
PIiItMITISSUANCE .
APPLIANCES - RESIDENTIAL
PANELS
III" 1'0200AMPS
201-1000 AMPS
OVER land AMPS
SIGNS ELEC'I'RICA].
T'EME ME'1'IJt OR POLE INST.
POWER DEVICES
SWIMMING POOL F,LE(: RIC
OUTLETS - SWT CHIS -FIXTURES
NEW RESIDEN'64A. .li(.TRR\ SQ rr
1'ERMI'f ISSUANCE l
ALTER - IRA IN&VENT
-WATIE (EA)
BACK FLOW PR(YTF.Cr. DEVICE
DRAINS - FLOOR, kOOP, AREA, CANG
FIXTURES = PER TRAP .
GAS -ITA. SYSTEM-) INC.4 DUE 'LETS
GAS -EA. SYSTEM OVER 4 (EA)
GREASETRAP
SEWER -SANITARY -STORM EA. 200 FT.
WATER H ITAFER W/VENT/ELECrR
WATER SYS'I'EMITRIiA1'INC.
WATER SERVICE
NEW RESIDF.NTIAI. PLMB. SQ. Fr.
MECHANICAL PERMIT'
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT HTO 10,000 CFM)
AIR HANDLING UNE '1'(OVER 14n00 CFM)
EXHAUST HOOD (W/DUC )
I HEATING UNIT (TO 1110,0011 B'N) .
HEATING UNIT (OVER 100.009 HI'1'U)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP UHPOR I(A)1000I TU7
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Fr.
- I
OFFICE
o
❑
$NQ. ill
. it ', ';, BUILDING PERNII•r INFO •' t
BLDG ELECT PILUMB MECH
FIV ❑ I��r
22 VALUATION
�'1
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑ KI'TCHEN RIiMODIiI.
❑ ADD] T]ON ❑PLUMBING RE -PIPIT
'EIMUCH-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
DAPROVINENT E]SWIMMING POOLS
❑ MATH RI,MO JREPAIR DEMOLITION
❑OI'HI?I2 fw
YPE CONSRUCI
' ;(ICG GROUP
APN
BUILDING DIVISION F.S
COMMERCIA1,
El NEW BLDG/ADDITION ❑DEMOLr1'ION
❑TENANT ❑ FOOD SERVICE
IMPROV17MENT
❑ OTHER
I'hANCHECK hEF.
PLUMBI G FEE
MECHA ICAL FEE
CONS UC'I'IONI TAX
I IOUSI G MITIGATION FEE
PAID
Dvtc RceciPt p
• 'IOTnL:
ISSUANCIi DATH-
ISSUED BY:
SQ. FI'. FLOOR AREA
AUG 1 RECD
CITY Ur uwoilIN
$NQ. ill
r•EE`.j
22 VALUATION
�'1
STORIES
YPE CONSRUCI
' ;(ICG GROUP
APN
BUILDING DIVISION F.S
I'hANCHECK hEF.
ENERGY FEB v )�
GRADING IT '
SOILS P"
PAID
m Receirtp
'l )IAL:
PLUMBI G FEE
MECHA ICAL FEE
CONS UC'I'IONI TAX
I IOUSI G MITIGATION FEE
PAID
Dvtc RceciPt p
• 'IOTnL:
ISSUANCIi DATH-
ISSUED BY: