99120002IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO
B:NhDINGDIVISION APPLICATION/PERMIT Pl.uhlBlN'G-
N 1111 : PY
IIINeII IF'
11074 MKp,(.'(
CONTRACTORS
00
CONfACI:,�5d,,�� PHONNE: Loy Uatru%, I r% YDo-so
DaaREI.i -Hsu C-Ivsi) 406 - 5273 Consultant Fees Paid by Applicant (Initial)
1 herebyfirm that 1 am licensed under f Cha mr 9 (commencingQTY ELECTRIC PERMIT FEE
. previsions p
C=Z with Scamn]O(0)d Division 3 afthe Buxinec. and Padeaions Code. and any Gcenm is
YAC in lull force and etto'l.
CUFsc Class Y
Li<.
a Liumc cla
�iaa U Dme Contra""'
ARCHITECT "S DECLARATION
e C H Z I undersand my plans shall be used as public records
7Z
C Y :1 Licensed PrefieW...I
OWNER -BUILDER DECLARATION
y d' a 1 bureby alirm that 1 mu exemPl from the Contractors License Law for the
`C, d U olLwing reason. (Sacllnn 70315. Business and Professions Cuda. Any city or county
- Nwhich require. a permit to construct, alter, improve, demolish, structure— r repair any strucre
3Oa
Pdnnuits i ... sm,e,.lw requires thespplicanl for such permnm file. signed looluoul
} that he is licensed pumuam term Provisions nftha C,ntracmrs license Law (C
(commencing with Section]aW)OfDivisinn3orfIn, Business and Professions
d c that he is exempt therefrom and the basis for the alleged exemption. Any violu is
0.1
W n L Section 7031.5 by uny applicant for a permit subjects We aP11W.W m a civil pe
h of more than fisc hundred dollars (851X).
G❑ I, an owner of the property, or my vludaya:s with wages as Meir ole co arlio
,It do Newnrk.and thle
c,,nmmreisnot inndedoroffen:dfnrmlviSer.7 Busine.
13 and Profession, Code: rUm Contractor., License Law does nm apply man mvner
property who builds nr improve, thereon, and who does such work himself or throng
his awn employees, provided that such impmvemenn are not intended or offered for
sale. If, however, the building or improvement is sold within one year of comp)
miner -madder will have the burden of proving that he did not build or improv
(].f, n, ownnr of the prn(w", ant is, lusivdy enmmeling with Ii ... oid cunnis
m.(,at, the prnjua (See. 7044, Busitma, and I'mfcss S Code,) The CoMmcmis L, -
cerise Law does not apply to an owner of property who builds or improves thereon, and QTY.
who[Pnlmms for such projectS with a contractons) licensW pursuant nt the Co ort, lis
License Law'.
❑lam e¢mpt and r.ec. .B&P C for this rearm
caner Dam
L lb
i 'S(fOM PINNA I ON DECLARA PION
1 hereby allirm undor penalty of perjury one of the following dcdvrmions:
1 have and will mainlain a CenlBcam of Cnnwul o, self -insure for w'orker's Com,n
sahun. as provided for by Section 37M of the Labor Cade, for the Performance of the
work for which this pc.it is issued.
El 1 have and will maintain Worker's Compensation Insurance, as inquired by Section
3710 of the Labor Code, for the perfmm.nce of the work for which this Permit is ismed.
My Worker sCtnfelowtiunIrt.anow, crier uad Policy numbser am:
Carrier: Policy Nn:
C17R'I IFICA 'I'1. Op EX L'M F] )ON PROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is forme hundred dollars ($100)
or les,.)
1certify thatinthenmnnof thework for which this permitiSissued ,lshall
Pcrs
not employ any
un in any manner
Sn as in become subject n the Workers Compcn-
Z xation I.—tilClil'nmia. Data
ZO Appheam
y
NOTICE 50 APPIACANT'. If, after making Win Cvmfream of Exenptlom, you should
bernme Subject In the Worker's Compensation provisions of the labor Code, you all
fonhwi h comply with such provisions or this permit shall la deemed revoked.
0.0
CONSTRUCTION LENDING AGENCY
U0 1 hereby alarm that Were is a construction lending agency for the Performance of
W P the work for which dos lemur is iward (Sec. 3099, Co. Ca
U Lender's Name
} Lender's Add.,
G I cenify that 1 have mad this application mid sate that the ohne information is
F' N nmeCt. l agree to comply with all city and county ordinances and sue law, relating m QTY.
U Z building construction, and herebv authorize mprescnlmives ofthis city to enlerupon the
uhwcmentomid property for inspection pmpoax.
(We) ugnor In save, indemnify and keep M1urmlea the Cory of Cupertino.gainxl
Iiubilifies, judgmenl,s, cuss and exlrvnses which miry in any way accrue ngainsl miA Ciry
Wegmming .1 no
APPLI . UNDERSTANDS ILL COMPLY WITH ALL NON -POINT
SOUR REGULATIONS.
HAZARDOUS MAIERIALS DISCLOSURE
W ill the uppllcata nr Wouchuilding nccupun. mom nr bundle nuardmo nsumeial
as defined by the Ctrammo Municipal Calc. Chapter 912, and the Health and SaWry
Code. Section 25532(.)'1
❑Yes E] No
Will the applicant or future building occupant use equipment or devices which
Out hamrdous air conuminantx as defined by the Bay Area Air Quality Management
Ilisuict?
❑Yee ❑Nu
I It a mod the hacudous nalerial.s requirement, under Chapter n 95 of the Cut.
boomII & S.mty Code, SmtionS x$505, 25533 and 155311 understand that if the
buildin snoccumudyhsocnit 1.Ihalitismymsponsibilityurn,> fythe occupant
PERMIT ISSUANCE
APPLIANCES-RIi51DEN'I AL
PANELS
UP TO 200AMPS
SIGNS ELECIRICAL
n
BUILDING PERMIT INFO
&— ELCCT,
BLDG
L�(
PLUM) ME❑CI{
JOB DDrEESSCRIPTClON
RESIDENTIAL,
❑SFDWL
,,--,,LL
IFYIOfCHEN REMODEL
[]ADDITION
❑ PLUMBING RCPIPE
❑MUUFI UNIT
❑STRUC'I URAI,
STORI e
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑ DEMOLITION
❑ OTHER
GREASETRAP
KFEE
COMMERCIAL,
❑ NEW BLDGIADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OU{F,R
'1111111 — 11111
NEW RESIDENTIAL ELECIR S FT.
FtT
FEE
SQ, FT FLOOR AREA
SISQ. trip.
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WAI FR (GAJ
VALUATION
3 .\ T to f�
V CTTYYPECONSTRUCf10N
BACK FLAW PROTECT DEVICE
DRAINS -RAOR, ROOF, AREA. CONE
STORI e
FIXTURES - PER TRAP
GAS-EA.SYSTEM-1 INC.40UTLEIS
OCC.GROUP
��APN
GAS - EA. SYS'I FM -OVER 4(EA)
GREASOINDUS'I RL WASTE INTERCEPTOR
BUILDING DIVISION F13LS
GREASETRAP
KFEE
SEWER -SANITARY- STORM EA. 201 FT.
ENERGY FEE
WATER H HAI LR WIVENTIELCCI'R
GRADING FEE
WATER SYS'I HMTREAHNG
SOILS FEE
WATER SERVICE
PAID a.. _ • �'-�
__ • wR���in�Y
NEW RESIDENTIAL PLMB. SQ, FT
MECHANICAL PERMIT
FEE
SE,SIKF
U
PERMIT ISSUANCE
F.LECOUC FEE
ALTER OR At)]) TO MECIL
pilbRING FGE
AIR HANDLING UNIT (TO 10.()(1) CPM)
M[CHANICALFEE
AIR HANDLING UNIT(OVER to." CFM)
CONSTRUCTION TAX
EXHAUST HOOD (WMUC)
HOUSING MITIGATION FI?I?
HEATING UNIT (TO 100OX) I3'1'U)
HEATING UNIT (OVER INL000 BU)
PAID
;.
VENTILATION FAN (SINGLE RESID)
Date Receipt#
TOT
IK2
BOILER - COME, OHP OR 100,000 BTU)
BOILER-COMP(OVER loo.upo BTU)
AIR CONDITIONER
ISSUANCE DATE
/ 'Z
ISSUED BY: • Y
NEW RESIDENTIAL MI CH. SQ. Fr.
TOTAL:
OFFICE