S 0638FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT
BUILDING DIVISION APPLICATION/PERMIT
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10,120 0E
OWNER'S NAME: PHONE:
�j'-$-'-ia.Z�(
"TNTRACI'OR:S NAME: LIC NO:
_65 Eh0 6u A16. B/ DrS
NIC
❑
CONTROL
�R; t{r tD HQ LIC NO:
q7 (}s REnDDSte.vG B14D9JY0
ADDRESS:
SRnE A9 A=��E
CON'I'AC'E PHONE:
-
BUILDING FER❑
BLDG EEE. MI?CHa
`ZLI!LIC[NSED
3-aLr7
Consultant Fees Paid by Applicant(Initial)
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CONTRACTOR'S DI!CLARA'I'ION
I herehy affirm that I ten licensed under Provisions of Chapter 9 (commencing
with Section 7166) of Division 3 of the Business and Professions Gale. and my license is
at 1115 vnd cffc O Sy0
License LiaM
Date Contractee
QTy, IiLECTRIC PERMIT FI7E
JOB DESOR
JOB
RESIDENTIAL
❑SFDWE ❑ KITCI II!N REMODEL
DITION. [J PLUMBING RE -PIPE
ULT(-UNR ❑STNUCfUNAI.
MODIFICATION
C1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑BATfi REMODCIIREPAIR El DEMOLITION
[I EITHER
PERMI'1'ISSUANCI!
APPLIANCES -RESIDENTIAL
Fly
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ARCHITECTS DECLARATION
I understand my plans shall be used as public records
PANELS
UP10200AMP5
or.„F-W
JOWNER-BUILDER
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Electoral Professional
DECLARATION
1 hereby animation I am exempt from the Comment's License Law for Ne,
following reason. (Section 7031 5, Business and Professions Gale: Any city or county
which requires a Permit mm construct, ldtr, improve, demolish, or repair any stmcwre
Frictionsi... mar, also outlines ow.pplicanl for such permino Me asigncdatmetnea
min licensed pl....atIn the prooWlarsof the Camvemr'I License Love(Chapter 9
fnnnmmming with Section ]lKKBof Division nDhc Business and l'ndceeinnx Codc)nr
that he is esempt therefrom cad the heels for the alleged m unplart. Any violation of
?031.5 by any applicant for a permit subjects the applicanrm a civil Penalty of
n more than Eve hundred dollars ($5 W}
❑Las owner of the property, or my employees with wages as their sole compcnvmion,
willdothework,vndthe suucwreistintintendedaroffered foradc(Scc.74,Business
and Pmfcs!nns Code: The Conoweem s License Law does not apply to an owner of
propeny who builds or improves thereon and who docs such work himself or through
his own employees, provided that such improvements am not intended or offered for
sole. If, however the building or improvement is sold within one yearmfcompletinn,the
wncobuilder will have the burden of paving dust he did not build or topmost for Pur-
21)1-1000AMPS
OVER IgN1AM1'S
SIGNS ELECTItICAI.
SPECIAL CIRCIJI'1'IMISC.
Ti!M I! M IT) OR POLE INS'(',
COMMERCIAL:
t
❑ NF W BLDG/ADDITION - 0 DI:MOL1'I'ION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT'
[]OTHER
POWI714 DEVICES
SWIMMING POOL ELECTRIC
OUTLRfS- SWI 'ICKES-I9XI'URFS
a
NEW RESIDENTIAL ELEC R SQ ET.
SQ. FT. FLOOR AHij), A
ESQ. FT.
Pose of ealeJ.
E] 1. as owner of the property, am eachooely contracting with licensed emenecmo m
nnsuum the project (Sec. 704,1, Business, cad Profeaeions Cnde:)'. he Coamctnr's Li-
cena,Law does not apply to an owner of properly who builds or improves thereon, and
1 `
- AN.' 5
ANS'D
-
QTY. PLUMBING PERMIT FEE
who cnnmuna for such Prnjedv withacomw'as(sl licensed Pursunmmthc Cnmranors
License Law.
Imncxemm un dem Sea. B& 1' C for this reason
CJJ7 ur isuF'
IS I lilt
PURMI'1ISSUANCE
Dwner Dale
WORKERS COMPENSATION DECLARATION
ALTER - DRAIN ffi,V ENT- WATER (EA)
BACK PLOW 1'R(YI'[CT. DEVICE
VAI.UA'I'ION
/
_
have and will mai under Penalty of oforyeneofthefnllowior declarations:
�[I have mdwill maimaineCmifcam of Consenttofor Workers Cnmpcn-
'ran, as provided for by Section 37M of the Labor Code, for the Performance of the
work for which this Permit is issued.
-
'DRAINS -I'LOOR, ROOF, AREA, GOND.
STORIES
-
TYI'li C(]NS'1'RUCTION
FIXTURES - PER TRAP
GAS- EA. SYSTEM. I INC. 4 OUTLETS
❑ I have and rill maintain Workers Compensation Insurance, vs required by Section
37W of the labor Code, for the performance of the work for which this Permit is issued.
'
OCC GROUP
AI'N
GAS -EA. SYSTEM -OVER 4(EA)
My Worker. Cyte ymil insurancpe 'rand Policy numMr arc:
Canicr. C oy F+t as ll Policy Nn.: _r �jo/Stip
GRF.ASIJINDUSTBI. WASTE INTERCEPTOR
CERI'ERCATEOFEXF.MPHON FROM WORKERS'
COMPENSATION INSURANCE?
BUILDING DIVISION FEES
GRGASB'I'RAP -
PIANCHECK FEE '
(Ihissvefmn nerd nm beearrldeed if the penult is for one hundred dollars ($100)
or less)
I cemly that in the performance ofthc work file which this Permit is issued, l shall
hilt cnmloy any Person in any manner xo as m become suMm nm the Worker.i Gmmpen-
SEWER- SANITARY-STGItM A. Ff.
ENERGY ItiE
WA'1'I!R IIY.A'1'BR W/VI!NT/ILL '
GRADING PFEEApplicant
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anioa law, of California. Datel
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NOTICE TO APPLICANT: If, after making this Cromena of Emit you should
become subject m the Worker's Compensation pmvixions tl the Luhnr Cale, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
(hereby of ran thatthem is a comtrvction lerulingagcncy forte ped ..are of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name -
WATER SYS D!M/fREsTING
WATER SERVICE
SOILS FEEIt
LAID Da /9d
OTA .
NEW RIES IDENTI AL PLMB. (.// SQ. FE
TOTAL:
L'mdceIAddress
I certify that 1 have read this application tend state that the manse information ie
career I.,me m comply with all city and county ordinances and swot laws relating to
buildingcensouction, end hereby authodm afacsenwtives of thiscity m ameruPon the
BUILDING P I b ig
QTY.' MECHANICAL PERMIT- FEE
SEISMIC�1
PERMIT' ISSUANCE:
ALTTiRORADD' IGMECIL
ELCCf
'(Wel
aMrvomen ianW Property for inspection Purposes.
agree m save, indemnify cad keep hat the City of Cupertino against
Ilahilitiex,judgmmnts, costs and expenses which may in any way accrue against said City
in samsequence of the 6maling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
PLIIMBINC FEI
.AIR HANDLING UNIT('11O 10,OW CPM)
MEiCHANICALF '
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of AppintualCurnowmr Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST' HOOD(WIDUC)
HOUSING MITIGATION FE'
DBAI'ING UNIT fT 014,000 BTU)
Willtheapplivent or furore building sweeprmourem handle hassummx material
as defined by the Catalano, Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section Z532(a)? -
HEATINGUND(OVER IBB,t BTU
VENTILATION PAN (SINGLEF 1
aS
(tYes ❑ No
Will the applicant or future holding ..,at use equipment or devices which
emit homdnux air conwminants as defined by the tiny Amu Air Quality Management
PAID Uma Receipt p -
BOILER-COMP(3HPOR IW. BTT) '
TOTAL.
Di aricl't
❑Yes We
poll.lilt- COM l' (OVER I W,IMNI OTU)
-
ATR CONDITIONER
I lave read the hnwrdous mmeriuLs rcgelmatents under Chapter 695 of the Coli-
ISSUANCE DATE
NEW IdESID1!NITAL. MECT SQ.Ff.
hmmie I health A, Safety Gale, Suctions 15505,2553.1 and 25534. 1 t cmwnd that if the
building draws nut eumally have a tenant, that it is my m,,,a ihility m notify the oecapom
of that r, acres priorto issuance ofn CCc�a�fO�upancy.,r
7
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TOfAI.:
ISSUED BY: