00010089APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDING DIVISION APPLICATION/PERMIT
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L IT CT/ENGINf:BR: LIC NO', AD RISS:
CDOM C y G013Co3 a ;siov
'ONTAC'f: s PHONE:w ^df ,
�o -60,,-6-VV 441Tr-Z0 � � � ❑Consultant Fees Paid by Applicant (Initial)
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
CZp with Section 70(abof Division Sof the Husinssi
ess and Profeons Coe and my licenseis
in full force and effect. 4
V U F LicenALiv. #
Dae e TCTS D
ECorL
oo
ARATION
y I underwandmy Plion,hal be uced is public records
F W Licensed Professional
-� OWNER -BUILDER DECLARATION
6 1 hereby ofirm that I am exempt from the Comorch is License Law for the
G U following arson, ISer,om 70315, Hucinas, and Pose,00ns Cock Any city m county
W vFi which requires a permit m construct, alter, Improve. demolAh, or repair any unin"me
prior to its issuance. also requires the applicant for such permitto file a signed statement
}a� that he is licensed pursuant to provisions of the Contractors license Law (Chapter 9
qQ (commencing with Section 7000) of Division 3 of the Business and Professions Code)or
C that be In exempt thercfrnm and list bads for the olleycd e¢empfon. Any violation of
LL• Section 9031.5 by any applicant for a permit subjects The upplicant to a civil penalty of
Z N not mom than Eve hundred dollars (S500).
SQp ❑has owner of me propeny. nr mY cmPloyees wish wagesaz m<ir sole compensation,
F will do thework,andthe stmcwreisnot intended or offered for sale(Sec.V044. Business
3 m and Pndcssion, Code. He Cormators License Law due, not apply to an owner of
property who builds or improves themon, and who does such work himself or through
his own employees, presided that such improvements arc out intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner builder will have the burden of proving that he did not build or improve for pur-
lose of "lay
❑ 1, as owner of the propeny, am exclusively contracting with licensed convacmrs to
constrict the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
verne law does not apply to an owner' of property who builds or improve, memos, and
who contracts for such projects with acontrac r(s)ImWpernametoma Conuannrs
ElI to Lou /J
am teemP un t§(� H & I' C fir tryyrcason
�II hereby rffirm under penalty of perjury one of the following declarations:
❑ 1 have and will ami stain a Can ificare of Consent in self -insure lin Worker's Compen-
sation, as provided for by Section 3707 of the Labor Code, for the performance of the
work for which this pemtit is issued.
❑ I have and will maintain W'orker's Compensation Insurance, as required by Section
19fg7 of the Labor Code, for the pe,ho mance of the work for which this permit is ixsued.
My Wnr' sConrpensuTlan Ins, gt nrtierand Pol'sy num tin �.J—��
Cartier. (�.PolicY Nu.: re '�"""`�
CF. rill PE OP 3MPTION MOM W RKERS'
COMPENSATION INSURANCE
(This section need nolbe completed if the pemrit Is forone hundred dollars (SIM)
or less)
I certify that in the pert aneeo p�rkfo hieh th''lslIpe�{fl is i d,isort
not employ any person Boner s x subjectp ( p riAgORn-
Q z smim laws of r O G•R.fJ
z Q Applicant
r%) NOTIC'E'f0 APPLICANT: If, after, making PS Cenifcme of Exemption, you should
abecome subject to the Workers Compmtsation provisions of the Labor Code, you must
W ford ith comply with such provision or this pemtit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
V O I hereby affirnnhuvhem isa construction lending agency for the performance of
4i. the work forwhop this permit is issued (Set. 3097. Co,. Cj
Lenders Name
r U Lenders Address
ly 1 rwity that 1 back read his m PPI ndim add suite t that the insove 'cif ardi is
Vi correct. I agree to comply withall city and county narrators' d vartle laws rcPTingto
V Z hard' It, con,arminion, andl by molhoor. relao,canumovofd t,1. ame, upon the
cisco tinned propeny( pecfonpryo s
(We) agree m save, moronity and keep hmmlesa the City of Cupertino till
liabil ities. judgments, costs and citpenses which may in any way acerae against said City
in cnn,cyuencc of thegranting of this permit
APPLICANT UNDERSTA7�pS A CCDM/PLY WITH ALL NON -POINT
SOURCE REGULA'}•,)yS,/f�{�L L.0 / /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant afore or handle hvallous martrod
as defined by me C.panino Municipal Code, Chapter 9.12, and the Healtb and Safety
Cade, Section 25532m)?
Yak )4
❑Will the applicant or future building occupant use equipment or devices which
lamil haaallous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes K.
have read the hmallous matcnT remcnts under Chapter fi 95 of for CA-
fomla Hamer A, aft Me. Sect 3 set 3J and 25534. 1 undemand that if me
buildingdoe yha a t ismyrespmsibilityta)Vtifytlycecup t
't TI:LdCIRttt, ren
-.,-
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
IJP TO 200 AMPS
OVER I"AM PS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE [NST.
MOWER DEVICES
(OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR
'MBING Pt ERMIT
.RMIT IS, A
of
ALTER — DRAIN&VF -W
BACK FTOW PROTECT. DEV ' v
DRAINS- 171.00R, ROOF, AREA, CO D.
FIXTURES-PERTRAP
GAS - EA, SYSTEM -1 INC. 4 OUTLETS
GAS - FA, SYSTEM -OVER 4 (EA)
GREASEIINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY - STORM EA. 21M IM
WATER HEATER WNENVELECfR
WATER SYST1iM!TREAI'ING
WATER SERVICE
k VI
M
BLDOADDITION ❑DF.MOLII'ION
NT ❑ FOOD SERVICE
❑ OTHER
I I NEW RESIDENTIAL PLMB. SQ. PT I I
TOTAL:
MECfIANICAI'PERMIT st
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR IIANDLING UNIT (IY) 10.000 CPM) f
AIR HANDLING UNIT(OVER 10,000 CPM) t'
EXHAUST HOOD (WIDUCT)
HEATING UNIT (TO 100,0011 BTU)
HEATING UNfI'(OVER 100,0110 RTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100.000 BTU)
HOILER -COMP (OVER In)." BTU)
AIR CONDI'r10NER
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
HUILDINGDIVISION FEIiS
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date
_ BUILDING HE
IEEE SEISMIC FILE
ELECTRIC
I HOUSING MI FIGAT10#1 FEE I
PAID I r I -_
Date Receipt#
TOTAL:
ISSUANCE DATE
ISSUEDBY. J�
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION' ❑PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
❑INTERIOR - FI CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOLS
❑ BATH REMODEUREPAIR (]DEMOLITION
❑ OTHER
BLDOADDITION ❑DF.MOLII'ION
NT ❑ FOOD SERVICE
❑ OTHER
I I NEW RESIDENTIAL PLMB. SQ. PT I I
TOTAL:
MECfIANICAI'PERMIT st
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR IIANDLING UNIT (IY) 10.000 CPM) f
AIR HANDLING UNIT(OVER 10,000 CPM) t'
EXHAUST HOOD (WIDUCT)
HEATING UNIT (TO 100,0011 BTU)
HEATING UNfI'(OVER 100,0110 RTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100.000 BTU)
HOILER -COMP (OVER In)." BTU)
AIR CONDI'r10NER
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
HUILDINGDIVISION FEIiS
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Date
_ BUILDING HE
IEEE SEISMIC FILE
ELECTRIC
I HOUSING MI FIGAT10#1 FEE I
PAID I r I -_
Date Receipt#
TOTAL:
ISSUANCE DATE
ISSUEDBY. J�