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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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DIVISION APPLICATION/PERMIT G.
BUILDING -- PERMIT NO,
CITY OF
C DPLUMBIN-MECHANICAL.
BUILDINGDIVISI%,n, covr mall.rTlm.11.1'ATION .. J 1L
2:310 La Solla. Ct
w I ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CON9'RACTOR'S DECLARATION
1 hereby iffirm than 1 um licensed under pow;, ome al'Chapter 9 (mtmme.cimg
with Section 7000) of Division 3 of the Business and Professions Code, and Tsay license i.,
in lull force and efieTi. r
Lice las Lic.X
hale Cotnrannr
CHITF.CT'S DECLA ON
oad�r,trvr I. ,,hall rl�Mic mcord,
I - OWNER -BUILDER DECLARATION
I hereby affirm akar 1 am exempt form the Cm ream's License Lew for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which require a permit In con%tun, aIle, rnpnn c, demolish, M repair any structure
prior to its iensed pursuant rsnyoirez the ;kiln, lin such permit m Ede s signedChapt eel
Lhahe Islicensed Seion T the provisionsof the Commnss Litems Law (, Capmr9
(commencing with Section TOM and the
I hark
3 of the Business and Posm. Ad,
Code) or
thio he is exempt therefrom .fid the husk for the alleged cxempiun. Any violation of
Section 7031.5 by any applieum for o permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
La sownerof the pmpeny. r is employees with sagesas theirsole 04LBsiness
will do the work, and the he Cmcanot intended oroffered ewdu, sale(Sea. team Business
and Professions Codor The improve,
Mercer.
License Law doec nm apply m if owner of
his o,roproy who builds or impmves thereon, and who doec such work
te himself fir through
his own employees, e pmlding trim such mentis old w are nm in. bernded m ciffieredpalms, for
sale. Ilhowever, the buildingorlen A ra,ir, issddwithinon,
yearofcompletion,the
�r-builder will have the M1urJen of proving than he did not build fir Improve for pun
Iwo of sale.),
Fl L as osvnerof the pm,My, am eaclbsivdy vcnMcting with licensed contractors to
construct the project (Sec. 70k , Business and Professions Cole) The Comtmcmr s Li-
cene,c Law does not apply to on ow per of property who builds or impmves thereon. and
who contracts 1'o, sock pnrjen, with u cummnrn(s) licensed persu.nr to the Contractor's
License Use
❑ 1 tun ewmpt under Sec. . B & P C for this,mon
I QTY.( ELECTRIC PERMIT I FEE i
P17RMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPTO'_OO AMPS
SIGNS ELECTRICAL
SEECIALCIRCUrI'/MISC. `
TEMP. ME'R OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RF_SIDENTIAI, ELECfR
PLUMBING PERM
PERMIT ISSUANCE
LATER —DRAIN&VENT—W! 13
Owner - [)air
WORKER'S COMPENSATION DECLARATION 1113:1XTURES
FLOW PROTECT. OFVICIi
(: I hereby a1Bren under weahp of perjury one of the following dreliensimo
I have and will maintain a Cenificac of Comm�t m self -insure for Writers, Compce-NS— FLOOR, ROOF AREA. COND.
.,alio., as provided lin by Section 3700 of the Labor Code, fur he peffnfnwnce of tire
work for which this permit is issued. —1'ER TRA('O 1 have and will maintain Araker', Compensmian Insurance. as reposed by Section37M of thelmhnfCode. for thePerformannceofthe work for which thisp.it is issued.EA. SYSTEM -1 INCA OUTLETSCamerrEA. SYS EM OVER 4(EA)CERTIFICATE OF I EMPTI(IN FROST NORKF,RSSFJINDUSTRL WASTE fisirp CEPNRCOMPENSATION INSURANCIi0hi--tom recd not be camplcmd if rhe permit is fnrone lmahed dollars($1goSEIRAP
orher, .)
I cenify that in the performance of the work for which this permit is issued.I shall SIiWER— SANITARY —STORM EA 200 FI'.
not employ any penin in any manner m a, to Nevem, subject to the Worker; Co.,..
,Minn Lows of CuGforma. Dae WATER HEATER WNENIDELECI'R
Appllc.nl )
NOTICRTO APPLICANT, If, after making this Certificate of Exemption, you .should WATER SYS'FEM/TREAI"ING
become subject to the Wml,eev Compcn,aeon provisions of the Lake, Code. on all
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDEN I JAL ILMI. SQ. IT.
1 hereby affirm thin them i, a construction lending agency for the peformanee of
the work for which this permit is issued (See. 3097. Civ. C.)
Lenders Name -
I.eodel,Addm,,
1 cenify that I have read this application and %ate that the above informminn i.,
Greet. l agree to comply with all city and county ordinance, and state lawn reining lin QTY.
building or,mcnon. and hereby utnhoriae mprescnmtive,of this city w enter upon the
ahnve-mcmioned pro'cly for inspen Inn purposes.
WO agree to,ve. indemnity and keep harmless the City of Cupertino against
cos¢<apenses which may in any wayaccroeagainst said City
yuenc fdhc"notmgo this permit.
APPLIC NT O DERSTANDS ND WILL COMPLY WITH ALL NON -POINT
SOURCE RE DTII l'S. 9' L,'
k 1
HAYARDOUS MATERIALS DISCLOSURE
W II the applicant or future building occupant store or handle hmaNnus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.)1
❑Yes MN.
s„ Will the applicant or future building aven,am use equipment or devices which
tvmjuus air contaminants as defined by the Bay Arco Air Quality Management
Dixlrictl
p Yes 0 N
I have read the haiadou, Materials requirements beau, Chapter 6.95 of the Cali-
fomfa Health & Safety Code. Sections 25505, 25533 and 25534. 1 meder,umd Nur 11 he
building does not comply have a ¢num, that it is my m,, mlbili , to notify the nertgeo t
of rhe requirements which must be met prior to issuance of a Certificate of Occupancy.
MECHANICAL PERMIT
PERMI"T ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING Cat T(r0 MOM CFM)
AIR HANDLING UNIT (OVER 10.000 GYM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT TO Ifid,010 BTU)
I IGTING UNIT (OVER I00,00O It I'U)
VENTILATION FAN (SINGLE RESID)
BOILER — COMP (HIP OR 1 W pp H'TU)
BOILER—COMP (OVER 000,Q)T BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH, SQ. PF.
G l2
N/C CONTROL
❑ &,tl 7
BUILDING PERMIT INF(
JOB DESCRIPTION
RESIDENTIAL
ENERGY 19iB
❑ SFDWI.
❑ KITCHEN REMODEL
111 4DDITION
El PLUMBING RE -PIPE
❑N LTI-UNIT
❑STRUCTIIRAI,
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
C]SWIMMING POOLS
❑ RATH RHMODFJ1REPAIR
❑ DEMOLITION
❑ OTHER N f
A
FR IAL:
//II//i�
❑NEDGJAiDIT10N UI!NIOLITION
❑TENANTV. (//'� I].;UOD SIiRVICE
IMPROVIIMENT
❑OTHER
SR IT R.00R AREA s/SQ. FF
FEE �5�
Iso
OlAt g'e
PLANCHFCK FEE
ENERGY 19iB
f
GRADING 1791
SOILS FEE
PAID
re Receiptp
FEE SEISMIC
-OFFICE -
MLCHANICAL Fli % Q�
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Reacipl x
ISSUANCE DATE
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