S 4434APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
❑ Consultant Foes Paid by Applicant (Initial)
1 hereby affirm that 1 am licensed under Provisions of Chapter 9 (commencing
Q`eZ with Scetiw7gk0,f llivisinn lm(the ltmincsmnd l'mfnsi... Gran. and my li... se
rn
F u, is in let tome and cttecyx
QU U License ` hies a Z7 ey
Nay Dae�Commcom _
ARCHITECTS DECLARATION
F m ZI mulcrsuu0 my plan., shall be a ... to, public records
OZ— _ -M
4 F- LL: Liccnsd
1'rofnsional
2447; OWNER -BUILDER DECLARATION
p, Y C Q 1 hereby :dorm (hal I am exempt from the Contractor's License Law for the
x 3 LLfollowing reason. (Section 7011.5. Business and i'mfessinns Come: Any dry or county
m which requires a pc.it m construct, aIle,, improve demolish, or repair any structure
E'NW��st prim,on, kouance.alwoes,destheapplicant formeh .it fleasigned statement
9999Ca�, that he is licensed purseam to the provisions of the Contmemr s License Law (Chapter 9
a�(commencing with Section 71N0pdDi,oio i Sof the Business; nd Professions Code) or
6 X c 0that he is emmpt therefrom and the basis for he alleged exemption. Any violation of
W = y Section 7031.5 by any applicant for a Earner subjects the applicant to a civil penally of
q r more than live hundred dollars (551)0).
2 G Las comerof the n yertp yecs with wages as Pensa
❑ properly, n, nn Ira rows mrh.nle rote don.
F• will do the work, and,he,memv is not lmendedorollered for sale (Sri. 70441 Business
W m and Professions Code: The Continuum's License Law dces not apply to an owner of
2 3 _ property who builds or improves thereon, and who d«s such work himself or through
his own employms, provided that such improvements are not Intended or offered for
sale. if, howeve, the budding or imprnvmnem is.old within one year of LOn.plelion. the
owner-buoder will have the harden of proving that he did not build or improve for pur-
ryxc of ole.).
❑ i, as owner of the property, am exclusively contracting with licensed contractors u,
,.iomed the Pmjml (see. 7(94, Baeonca ana Prote awns Code:) Tne Conlrncmr's Li -
cow Law does not apply to an owner of property who builds or improves thereon. and (yTY.
who contracts for such projects with a contractors) IiCenum Pursuant to the Contractors I Ate
License Law.
1.m exempt under Sec. . It is P C fur this reason
net Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain u Cmmfirute of Cab,ma m self-ia w,c for Workcr'sCnm er-
as Pmviokd for by Scretwo 3700 of the LaM,r Come, for the Pen arromee of the
k for which his permit is ismd.
I have and will maintain Worker's Compensation Insurance, as required by Section
f, of the Labor Cede. b, Ibe perp rut m cof the work for which this pet niI is issued
CERTIFIPAF. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This i..
need nut becotimic ed it the permit is for tete hundred dollars IS I q)
lest)
I cenily that in the pbramance of the work for which this patent is issued, l shall
not employ any person in any manner so as to become subject to the Worker,: Campen-
Z mion Lows of Calif in Date
ZO Applicant
NOTICE TO APPLICANT: IL after making this Cetifirme of Exanption, you should
(•" "' m,orm sable,, to the Worker'% Compensation provisions of the Labor Code, you most
�y G,boith m.nply with such provisions,, Ilii, pcnnit shall be decmd mvokcd.
a�
CONSTRUCTION LENDING AGENCY
U p I hereby affirm that there is a construction lending agency for the performance of
P the work for which Nix permit is land (Sec 3097, Civ. C)
O U Under Name
}WLenders Addre„
y I cedify that 1 have read this application and ,tate that the above information is
rvFr N s sect. 1 agree o comply with all city and county ordinances and state laws relating m QTY,
U Z building cosbactlole, and hereby authorize representatives of this citymnty upnntbe
almae-mentioned property for inspection policies.
(We) agree to save, indemnify mall keep harmless the City of Cupertino against
liabilities, judgments, tests and expenses which may in any way creme against said City
xqucncr of the grmning of this is, nn it.
APPLICANT UNDERSTANDS AND W ILL COMPLY W 1'I'H ALL NON -POINT
SOURCFERT rL S.
SignatureofApplicom' vnmctm Date
11?11ARDOUS MATERIALS DISCLOSURE:
Will the applicant or future building occupant store or handle hvaNaus material
;is def red by the Cupertino Monte Pal Code, Chapter 9.12, and the Health and Safety
Code Section 25532(.)7
E] Yeti E] No
Will the applicant or future building occupant use equipment or dcv ices which
it has admux ai. conw...innnts sedefined by toe Bay Area Air Quality Management
District!
[3 Yes ❑No
I have read Lha hwnrdou, materials requimmmats under Chapter b.95 of the Culi-
barin He.hh & Safely Code. Sections 255(15. 25593 and 25534. 1 uaderxland that It the
building dre,n hav amnam.ydyrt it is my responsibility to notify the occupant
of the auui ;uwhich ua be mea nr{rtoismance of a Certificate of(>/,:upgn¢._ _
ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES - RESIDENT 'IAL
PANELS
UP'10210 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
HMI'. METER OR P(B,IE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
PUTLETS - SWITCHES - FIST
NEW RESIDF,NHAI, ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA
BACK FLOW PROTECIE DEVICE
DRAINS- FLOOR, ROOF. AREA, GOND.
FIXTURES - PER TRAP
GAS-EA.SYS'TFM-1 IN40U 5
GAS - EA. SYSTIEh1-OVERC.(A)
GREASERNDUSTRL W . TF INTERCEPTOR
GREASE'rRAP
SEWER - SA' ARY-STORM EA. 200 FT.
WA'I'IB VAI ER W/VENT/FLECTR
NEW RESIDENT AL PLMR. SQ. Mr
MECHANICAL, PERMIT
ALTER OR ADD TO MECH.
AIR HANDLING ON] 'I' T O IF." CPM)
AIR HANDLING UNIT (OVER IO.WO CFM)
E%IIAUS'E UO)D (W/DUCT)
JIEATWG UNIT OO IUO." JOH)
HFAPING UNIT' (OVER 1(10,(X10 B'ru)
VILNTILATION FAN (SINGLE, RESID)
BOILER - COMP (3HP OR 100,(X1() 13'1'U)
BOILER -COMP (OVER 100.000 11 I'd)
AIR CONDITIONER
NEW RESIDEN HAI. SUCH. SQ. 14,
OFFICE
TOTAI,:
CITY OF CUPERTINO
BUILDING. ELECrR
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHAI
SANITARY NO,
APP (CATION SCENE PIAL (IAT
-/V-?y
BUILDING PROJECT IDEN'I
NIC
BUILDINGADDRESS; nn
'�2 93 5 O
rr
❑ Consultant Foes Paid by Applicant (Initial)
1 hereby affirm that 1 am licensed under Provisions of Chapter 9 (commencing
Q`eZ with Scetiw7gk0,f llivisinn lm(the ltmincsmnd l'mfnsi... Gran. and my li... se
rn
F u, is in let tome and cttecyx
QU U License ` hies a Z7 ey
Nay Dae�Commcom _
ARCHITECTS DECLARATION
F m ZI mulcrsuu0 my plan., shall be a ... to, public records
OZ— _ -M
4 F- LL: Liccnsd
1'rofnsional
2447; OWNER -BUILDER DECLARATION
p, Y C Q 1 hereby :dorm (hal I am exempt from the Contractor's License Law for the
x 3 LLfollowing reason. (Section 7011.5. Business and i'mfessinns Come: Any dry or county
m which requires a pc.it m construct, aIle,, improve demolish, or repair any structure
E'NW��st prim,on, kouance.alwoes,destheapplicant formeh .it fleasigned statement
9999Ca�, that he is licensed purseam to the provisions of the Contmemr s License Law (Chapter 9
a�(commencing with Section 71N0pdDi,oio i Sof the Business; nd Professions Code) or
6 X c 0that he is emmpt therefrom and the basis for he alleged exemption. Any violation of
W = y Section 7031.5 by any applicant for a Earner subjects the applicant to a civil penally of
q r more than live hundred dollars (551)0).
2 G Las comerof the n yertp yecs with wages as Pensa
❑ properly, n, nn Ira rows mrh.nle rote don.
F• will do the work, and,he,memv is not lmendedorollered for sale (Sri. 70441 Business
W m and Professions Code: The Continuum's License Law dces not apply to an owner of
2 3 _ property who builds or improves thereon, and who d«s such work himself or through
his own employms, provided that such improvements are not Intended or offered for
sale. if, howeve, the budding or imprnvmnem is.old within one year of LOn.plelion. the
owner-buoder will have the harden of proving that he did not build or improve for pur-
ryxc of ole.).
❑ i, as owner of the property, am exclusively contracting with licensed contractors u,
,.iomed the Pmjml (see. 7(94, Baeonca ana Prote awns Code:) Tne Conlrncmr's Li -
cow Law does not apply to an owner of property who builds or improves thereon. and (yTY.
who contracts for such projects with a contractors) IiCenum Pursuant to the Contractors I Ate
License Law.
1.m exempt under Sec. . It is P C fur this reason
net Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain u Cmmfirute of Cab,ma m self-ia w,c for Workcr'sCnm er-
as Pmviokd for by Scretwo 3700 of the LaM,r Come, for the Pen arromee of the
k for which his permit is ismd.
I have and will maintain Worker's Compensation Insurance, as required by Section
f, of the Labor Cede. b, Ibe perp rut m cof the work for which this pet niI is issued
CERTIFIPAF. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This i..
need nut becotimic ed it the permit is for tete hundred dollars IS I q)
lest)
I cenily that in the pbramance of the work for which this patent is issued, l shall
not employ any person in any manner so as to become subject to the Worker,: Campen-
Z mion Lows of Calif in Date
ZO Applicant
NOTICE TO APPLICANT: IL after making this Cetifirme of Exanption, you should
(•" "' m,orm sable,, to the Worker'% Compensation provisions of the Labor Code, you most
�y G,boith m.nply with such provisions,, Ilii, pcnnit shall be decmd mvokcd.
a�
CONSTRUCTION LENDING AGENCY
U p I hereby affirm that there is a construction lending agency for the performance of
P the work for which Nix permit is land (Sec 3097, Civ. C)
O U Under Name
}WLenders Addre„
y I cedify that 1 have read this application and ,tate that the above information is
rvFr N s sect. 1 agree o comply with all city and county ordinances and state laws relating m QTY,
U Z building cosbactlole, and hereby authorize representatives of this citymnty upnntbe
almae-mentioned property for inspection policies.
(We) agree to save, indemnify mall keep harmless the City of Cupertino against
liabilities, judgments, tests and expenses which may in any way creme against said City
xqucncr of the grmning of this is, nn it.
APPLICANT UNDERSTANDS AND W ILL COMPLY W 1'I'H ALL NON -POINT
SOURCFERT rL S.
SignatureofApplicom' vnmctm Date
11?11ARDOUS MATERIALS DISCLOSURE:
Will the applicant or future building occupant store or handle hvaNaus material
;is def red by the Cupertino Monte Pal Code, Chapter 9.12, and the Health and Safety
Code Section 25532(.)7
E] Yeti E] No
Will the applicant or future building occupant use equipment or dcv ices which
it has admux ai. conw...innnts sedefined by toe Bay Area Air Quality Management
District!
[3 Yes ❑No
I have read Lha hwnrdou, materials requimmmats under Chapter b.95 of the Culi-
barin He.hh & Safely Code. Sections 255(15. 25593 and 25534. 1 uaderxland that It the
building dre,n hav amnam.ydyrt it is my responsibility to notify the occupant
of the auui ;uwhich ua be mea nr{rtoismance of a Certificate of(>/,:upgn¢._ _
ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES - RESIDENT 'IAL
PANELS
UP'10210 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
HMI'. METER OR P(B,IE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
PUTLETS - SWITCHES - FIST
NEW RESIDF,NHAI, ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA
BACK FLOW PROTECIE DEVICE
DRAINS- FLOOR, ROOF. AREA, GOND.
FIXTURES - PER TRAP
GAS-EA.SYS'TFM-1 IN40U 5
GAS - EA. SYSTIEh1-OVERC.(A)
GREASERNDUSTRL W . TF INTERCEPTOR
GREASE'rRAP
SEWER - SA' ARY-STORM EA. 200 FT.
WA'I'IB VAI ER W/VENT/FLECTR
NEW RESIDENT AL PLMR. SQ. Mr
MECHANICAL, PERMIT
ALTER OR ADD TO MECH.
AIR HANDLING ON] 'I' T O IF." CPM)
AIR HANDLING UNIT (OVER IO.WO CFM)
E%IIAUS'E UO)D (W/DUCT)
JIEATWG UNIT OO IUO." JOH)
HFAPING UNIT' (OVER 1(10,(X10 B'ru)
VILNTILATION FAN (SINGLE, RESID)
BOILER - COMP (3HP OR 100,(X1() 13'1'U)
BOILER -COMP (OVER 100.000 11 I'd)
AIR CONDITIONER
NEW RESIDEN HAI. SUCH. SQ. 14,
OFFICE
TOTAI,:
❑BATH REhHIsDEL/JjEPkT,6-M(y,IITON&sl1t
❑NEWBLDG/ADDITION L1 DEMOLITION
❑MNANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
sn rvJ1POR AREA SISO. rel'.
FEE r JUL 14 �1,
By VALUATION
STORIES TYPE C(
OCC. GROUP
12- I
BUILDIME DIVISION FLES
PLANCHECK ME
ENERGY FEE
GRADING FEE:
SOI( S FEE
PAID G
X( Rcecipl X
TOTAL:
BUILDING FLEE
FEF SEISMIC FEF
a ELECTRIC FEE
PLUMBING FEE
MECHANICAL ITE
I HOUSING MITIGATION FIEIE
S 4434
SANITARY NO,
APP (CATION SCENE PIAL (IAT
-/V-?y
j
NIC
CONT'ROL4
BUILDING PERMIT INFO
BLDG ELECT
❑
PLUMB MECIi
❑
FEE
JOB DESCRIPTIO
RESIDENTIAL:
❑SFDWL
[]ADDITION
❑MULTIUNIT
❑ INTERIOR
IMPROVEMENT
❑ KITCHEN REMODEL
❑ PLUMBING RE PIPE
❑STRUCf11RA1.
MODIFICATION
[:1 CHIMNEY REEI'AIR
C]SWIMMING POOLS
e` O
J
❑BATH REhHIsDEL/JjEPkT,6-M(y,IITON&sl1t
❑NEWBLDG/ADDITION L1 DEMOLITION
❑MNANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
sn rvJ1POR AREA SISO. rel'.
FEE r JUL 14 �1,
By VALUATION
STORIES TYPE C(
OCC. GROUP
12- I
BUILDIME DIVISION FLES
PLANCHECK ME
ENERGY FEE
GRADING FEE:
SOI( S FEE
PAID G
X( Rcecipl X
TOTAL:
BUILDING FLEE
FEF SEISMIC FEF
a ELECTRIC FEE
PLUMBING FEE
MECHANICAL ITE
I HOUSING MITIGATION FIEIE