30982APPLICANT TO FILL IN INFORMATION
CITY OF CUPERTINO '
BUILDING DIVISION APPLI
_ BUILDINGADDRESS:
96
JWNERS NAME: - "P
o. HR. SA/'/ //0440"l
WITHIN RED LINES • USE BALL POINT PEN ONLY
" BUILDING - ELECTRICAL
CATION/PERMIT- PLUMBING.. MECHANICAL
BUILDING PROJECT MEN 'rIFICATION
• A'�'
C �/iF -,�Ti w a , �q , 7/x/53
SANIT/
HONE:
NTRACTOR'S NAME: LIC NO:
Gus 8�J %LyEes
-
NU
IC NU:
AD}QRBSS:' ,
3%01 G�,BoyDnN Av6. ,S•J. qSy
Q'
110NE:
„
❑ Consultant Fees Paid by Applicant (Initial)
BLD-
1 hereby offrn that 1 am ' licensed under provisions of Chapter 9 (commencing
th Section 900(9 of Division Sur the artiness and Professions Cale, and my license is
full fosse and eR' .
Lot,
fief — Cnmmetnr
ARCHITECT "S DECI.AkA'1'ION
I understand my Plans shall be uved as public records
QT' ELECTRIC P17RMIT I FEE
PURMTF ISSUANCE
F 4 = W Licensed Pmfcesimord -
bd�:�" OWNER-BUILDER DECLARATION
y R Q I hereby, affi nt that l am coman from the Contractor's License law for the
fd es following reason. (Section 7031.5, Business and Professions Code: Any city or county
F WO which requires a pfrom m construct. alter, improve, demolish, or repair any sou tare
prior to its issuance. also requires the applicant for such permit to file a signed .statement
�QE that he is ]accused pursuant to lire provisions of the Cnntmdor's License (aw(Chapter 9
IaS1 ( wmmencing with Secdnn 9fNkB of Divi�i�n3of mu Business roil Pmfessiom Cale)nr
L a. o that he i.e. exempt therefrom and the basis for the alleged exemption. Any viol i ir. of
—y Section 0031.5 by any applicant for a permit subjects roc applicant o a civil penalty of
of mom than five hundred dollars ($500).
❑I, as owner nfthe prnpeny, nr lny employees wnh wagesas duch is compensation,
will do the weak, and the comemre is not intended oroffered far stile (Sec. IIFI4, Business
and Precisions Code; The Conlracmr's License Law does not apply to an owner of
.property who builds or improves thereon, and who does such work himself or through
his awn cmpleyces, provided that such improvements are not intended or offered for
sale. If, however, tht bai]ding of improvement is sold within one year of completion, the'
er- builder will have the burden of proving that he did not build or improve for pur-
Pdm of sated.
❑ I, as owner of the prnpeny, oat exclusively contracting with licensed convectors to
summer the project (Sec. 7044, Business and Pofessons Cattle:) The Commerce• U-
enve law does not apply m as owner of property what builds ar improves datum, and QTY.
wtio contracts for such projects with a innumerous) hearted pursmtm lm the Convactots
License Law.
Of am exempt under Sec. ; B$PCfnr this reason
Owmer ! Date
WORKER'S COMPENSATION DECLARATION
Ihereby offirmunder Penalty of perjury one of the following dedarmmus:
❑ ]hove and will maimnin a CenilSCa¢ of Conscm msell''- insure for Workera Compen-
sation, as provided fur by Section 3900 of the Lmmf Cale, for the peffis mmaca of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3910 ofthe Labor Cade, for the performance of the work for which this permit is issued..
My Wurkc ?Minn Jgfwance- yryjfr and Policy nmpptryO paz
Caries �(//YJ/ Policy No, 2 Q
CERTIFICATE OF IWIMiTION FROM WORKERS'.
COMPENSATION INSURANCE
(This section need not he completed ifthe profit is source hundred dollars (5100)
or less.)
I certify that in the performance of the work for which this permit is issued. ] shall
not employ any person in any manner so as to become subject m the Workers' Compca-
O z section Laws of "California. Date
z Applicant
NO DCE TO APPLICANT If. after nwking this Cenilicam of Exemption, you should
a. become subject to the Wei Compenaation prnvisinnsof life labor Code, you must
{1•: forthwith comply with such pmvish or this pemrit shag hedeemed revoked
a
z . northe is aconNLENUINGAGENCY
U Q Ihereby union nor there is acnnstmetien lending agency for the performance of
u, Hthe work for which Nis perm I it is issucd(Sec. 3097. ON. C.)
Leader's Name
Landei.s Address -
1 eerily that 1 have rend Ibis upplicalion trod state that the above information is
In comet, I agree to comply with all city and county ordinances and state lows mluingm QTY.
U z building construction, and hereby authorize mprasentatives of this city to enter upon life
above- mentioned progeny for inspection purposes.
(We) agree m save, indemnify and keep roofless the City of Cupertino against
liubilities,judglnenls, costs anA expenses which m:ry In nny way accent against said Ciry
in rons cluence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Signature of ApplicandContmeor Date r
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occuprm from or handle hamrdous mmerlul
as defined by Ere Cannons, Municipal Circle. Chapter 9.12, and the Health and Safety
Code, Section 255320)!
❑Yes ON..
Will the applicant of furore building occupant usdequipmem er devices which
tit hazardous air mmmninano as defined by the Buy A= Air Quality Management
D'sme l .
Fl Yes 0 N
1 Imve feud the haunbus nationals "Wramems under Chapter 6.95 of the Cali -
fumia Health k Safety Coda, Sections 25505. 25533 and 25534. 1 understand that if the
tiuildingd not curmndy huveamount. that it is myraspmasibilitymnmily the mcup:im
of the s nt+wre an be- nearmonio,m actifn Ceniyjv�Iu:ta otoc agar�sy,
n..: /is
PANELS
UP T0200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCII'I /MISC.
TEMP. METI2R OR POLE INST.
POWER DHVICE:S
SWIMMING POOL ELECTRIC
NEW RESIDENI'IAI. ELECTir SQ Fr.,
PLUMBING
PERMIT ISSUANCE Z
ADIER - DRAIN &VENT -
WATER (I3A)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM.I INC. 4 OUTLETS
GAS -EA. SYSTEM OVER4 HIA) ,
GREASMNDUSTRL WASTE INTERCEPTOR'
GREASETRAP
SEWER - SANITARY - STORM EA. 200 FT.
WATER HEATER WNENTELECTR
WATER SYSTEMITRF,ATING
WATER SERVICE
NEW RESIDENTIAL PLMIL • SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE
AATER OR ADD TO MECI {, '
Alit HANDLING UNIT (TO IBM) CFM)
AIR HANDLING UNIT (OVER IQ(IW CPM) -
EXHAUST HOOD (WMUCT)
HEATING UNIT TO 103,000 B'IU) .
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESIDI
HOILER -COMP DHP OR 100,(0013TU)
BOILER -COMP (OVER IOgWn If rut
AIR CONDITIONER
NEW RESIDENTIAL MUCH. SQ .I
2ill, 4Lit
CONTROL 4
BUILDING P17RMIT INFO
ELECT PLUMB MECH
K1— 1-2511 4-
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ;AKITCHEN REMODEL .
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNrr ❑STRUCTURAL
MODIFICATION'
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
^NTH REMODEUREPAIR ❑DEMOLITION .
❑ 01 14H
COMMERCIAL'
❑NEWBLDG /AD61T10N ❑DEMOLI'r10N
❑TENANT ❑FOOD SERVICE
IMPROVEMENT
❑ OTHER'
SQ. FE FLOOR AREA ,
PAID
E 'FEB 18 KC11
I
I '
. -•'VA'U) M
'STORIES TY
BUILDING DIVISION PI ?Ii.S
PLANCHECK FEE
ENERGY FEE
GRADING FEI:
SOILS FEE
I -All)
Dote Rceeiptn
TOTAL:
BUILDING FEE
EEL. SEISMIC FEE
ELECTRIC FEE
PLUMBING TEE
MECHANICAL FEE
CONSTRUCTIONTAX
HOUSING MIT'IGAT'ION FEE
PAID
Date _ Receipt p -
ISSUED BY
OFFICE
TT) FAL
ISSUANCE DATE