S 0220APPLICANTTO FILL'IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILTN 3 - ELecralcnl. PERMrr NO
APPLICATION/PERMIT PLUMBING-hIF,CHpNICAI. S 0220
BUILDING DIVISION ,..n. rPLUMna, Nsa -M rCHANIureB•snv. \J
BUILDING
OW�AUURIl
�Cr AU__
PHONE: CO NR
2
ARCHITECI'/F.NGINECR: LIC NO: S �
CONTACT: �/J/- PHONE:
��jT// ❑ Consultant Fees Paid by Applicant (Initial)
1 heeehy affirm Nm 1 am licensed under provisions of Chapter 9 (commencing
with Section]0M0 ofSian 3of ma Business int nsC d,al anaein
in full force and cl t
a
I s ClCI .s "c vi LIC.N
Dale Contmcmr
ARCHITECTS DEC[ A Al OI
I understand my plans shall be used as public records
Licensed P..fesaional -
OWNER -BUILDER DECLARATION
I hereby a1'from that I am exempt from the Contractor's License Law far the
following roman. (Section 9031.5, Business and Profusions Cole: Any city or county
which requires a permit in construct, alleq improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit o file a signed statement
that he is licensed pursuant o the provisions of the Contmclnrs License Low (Chapter 9
(commencing with Section 9000) of Division 3 of the Business and Professions Cala) or
deet he Is axanpl therefrom and he hmis far the alleged axemmion. Any vimnlion of
Section 7031.5 by tiny applicant for a permit subjects [h0 applicant to a civil penalty of
not tame than five hundred dollars ($5(03.
I, as owner of the progeny, or my employees with wages as their sole conrpcmation.
will do the work. and the structure is not intended oroaered for sole (Sec.]04 ,Rosiness
and professions Coda The Csmmenirs License Law claws not apply to an owner of
property who builds or improves thereon, and who does such work himself or nhrnigh
his own employees, provided that such improvements are not intended or uttered for
sale. If, Im vovcr. he building or btprove nem is sold within one year of completion, Ilio
ownerbuilder will have the barren of proving that he did not build or improve for pur-
pose of wile.).
❑ 1, as ware of the property tion exclusively rontearting with licensed contractors to
crourVue, the project (Sec. ]Btu, Business and Pmacoma s Cade:) The Commgors Li-
cense Law does nm apply In an owner of pmpmy who builds or improves Ihercon, and
who contracts for such projects with a aimmemr(s) limmoul pursuant to [lie Contractor',
License Law.
❑ I am exempt under See. ,B& P C for this mason
Owner Date-
WORKER'S
amWORKER'S COMPENSATION DECLARATION
• ❑I hereby affirm under penalty of perjury one of the following desclamikes:
1 have and will maintain a Cenificatc of Coneentto sd6insum for Workers Cmnpen-
sutlea. vs pmvidad for by Section 37111 of the Luhnr Code, for the rourforramecol ho
vui�vfmr which this comit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Station
37M ofthe Labor Costs. for the pdffomiance of the work for whllb,hi panne s"".ad.
My Wn C rude artier end Pol'
Te Y
Carrie nv. Policy a
CERTIFICATE( iii%F.MPI'IONFM IF
WORKERS'
COMP17NSATION INSURANC17
(This ncdian need not be coniplctal if the pennil ix Iiirmm hundred dolllnn SIM)
or less.)
1 certify that in the performance of the work for which this permit is issued, i shall
n01 employ any person in any manner so as to become subject othe Workers' Cunnpen-
0z satin. Laws of California. Data
z 0 Applicant t
NOTICE TO APPLICANT: If, aflcr eking this Cenilicale of Exemption, you should
a become subject It the Worker's Compensation provisions of the Labor Cade, you nmst
forthwith comply with such provisions or this permit shall bo deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
UQ Ifar. hiffienhmlhetiso bunswc[ionlendinl agency for the perfnmemcc of
L4 H the work for which this penis s ismeJ (Sec. 3177, Ci, C.)
0U
Leader's Name
Adde
W Lendw'I mildly cerree Itml I have ithl thinly an conn and dime ria[ the above inhmnating is
as V] building l agree mime,complyand with all city and county uNidaneds and crura laws r upon t e
U building connmcninn, and hereby outhodze representatives of this city mercerup�n the
above-mentioned progeny for inspm6cor purposes.
(Ale) agme m save, indemnify and keep homeless the City of C.,mrn against
liabilities pollutants, costs and expenses which may in any way acme against said City
in com... a ce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applivma Cmrum1 it Dam
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant suite or bundle hazardous material
as carload by the Cupertino Mumap I Code, Chapter 9.12, and the Breath mal Salary
Code, Section 25532fa)9 /J'
❑Yes D(Nn
Will be applicant or fumm building a,.t use equipment or devices which
emit hazdNou.s air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Vis
1 have real the hazardous materials resuimmads under Chapter 6.95 of the Cali-
fornia Health & Safety Cade, Sections 25505. 25533 add 25534. I understand but if the
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPI '021X1 AMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
THMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ 17
PLUMBING PERMIT
1117RMIT ISSUANCE
AMER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECR DEVICE
DRAINS -FLOOR, ROOF AREA, COND.
19%'TURES - PER TRAP
CTAS -EA. SYSTEM -1 INC. 4 OUTLETS
CAS -P . SYSTF.MkOVFR 4(EA)
CREASIVINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY -STORM EA. 200 IT.
WA'I'F.R HEATER WNHN UHLE.CTR
WAI'17R SYSTEMrTREAT'INC,
WAI'I7R SERVICE
NEW RI'dIDENTIAL PI.MB. SQ. FP.
HU'Al.
QTY. ,MECHANICAL PERMIT
PHRMIT ISSUANCE
ALI'Ell OR ADU To MF;CIL
Alit HANDLING UNITC1010,010CFM)
AIR HANDLING UNIT (OVER 10.01(10 CFM)
EXHAUST HOOD IW/DUCT)
HHA'I'ING UNIT TO IMI,000IOU)
1117KI'INC, UNIT (OVER IMOX) BTU)
VENTILATION FAN (SINGLE RISID)
BOILER -COMP (3HP OR 10RODD BTU)
BOILER -COMP (f VDIt Iat" B'TU)
AIR CONDITIONER
NEW RESIDENTIAL MIKE. SQ. FE
SQ, Ff. FLOOR AREA S/SQ, 171
'r U7AON
l�
STORIES /i�/ TYPE CONSTRt1C'I'
OCC.GROUP APN
BUILDING DIVISION FRES
PLANCHECK FEE
ENERGY FIA:
GRADING FEE
SOILS PI2111
PAID
Date Recuts X w
BUILDING fl Ai Q
FEE SEISMIC 17EE
DELECTRIC FEE
PLUMBING hili
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION T
PAID
Date Receipt x
ISSUANC17 DATE
° -/o -- ?7
ISSUED BY:
PL❑DC F.Ler}f PLu❑Mn mt;cly
FEE
JOBB D,FSCRIPTION
RESIDENTIAL;
❑SFDWI. ❑ KITCHEN REMODEL
El ADDITION 11 PLUMBING RE -PIPE
❑MULTI -UNIT 0STRU42TURAL
' MODIFICATION
[]INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT E]SWIMMING POOLS
❑ BATH RIiMODEL/REPAIR ❑ DEMOLITION
❑ OTHER
I'
COMMERCIAL:
[]NEW BLDG/ADDITION ❑DI: 01,1'rinN
❑TENANT' ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ, Ff. FLOOR AREA S/SQ, 171
'r U7AON
l�
STORIES /i�/ TYPE CONSTRt1C'I'
OCC.GROUP APN
BUILDING DIVISION FRES
PLANCHECK FEE
ENERGY FIA:
GRADING FEE
SOILS PI2111
PAID
Date Recuts X w
BUILDING fl Ai Q
FEE SEISMIC 17EE
DELECTRIC FEE
PLUMBING hili
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION T
PAID
Date Receipt x
ISSUANC17 DATE
° -/o -- ?7
ISSUED BY: