99090140APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY 01 C,O a4_4 In
CITY OP CIPERTINO RUILIIING - N,I,F.CTRICAI. PF,RMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING A DURESS:
CONTACT,
lUN'IBACTOR'S NAME: P Ln
b14�'�721L nDw
:
'`BURESSD,I 3 zom A rN on¢, eti
❑ Consultant Feet Paid by Applicant (Initial)
I hush firm that I am licensed under ns of Chapter 9 (commencing1TY ELECTRIC PERMIT
y u protrusio p
uiOZ with Section](NN))of Divicod Sof the Bc,ior,n and Pndcsaims Cit le.and my f -ave is
F y in fall force and dfen.
QV U Licen lass tic. « 6
Ito W Dam �3�--. -S Cnmranor
ARCHITECTS DECLARATION
'ZOyZ„ l understand my plans shall be used a%public records
OZ --M
F ~ W Licensed Pmfea anal
Y OWNER -BUILDER DECLARATION
C C Q I hereby effort that 1 it, exempt Bon, the Contractors Lunate Law for the
3 Ffollowing reams (Section 7031.5. Business and Professions CoalAny city or county
which requires a wrout to construct, alcor. improve, demolish, or repair any structure
F `� prior, its insuranee, a6rrequlresthe applicant for xuch p,it mll m file.signed statement
i y Lha he is licensed pursuanttthConvenors
o e provisions of the m Licenw (Ch pier 9
m�00 (commencing with Section 9000) of Division 3 of the Business and Professions Code)or
d 11 e K this, he is even,it Ihuefrom and the basis far the allcsed cxmrtpion. Any violation of
mSection 9031.5 by any applicant for a permit subject are applicant to a civil penalty of
rn9 more than rive hundred dollars ($500).
Z� ❑ Lm cismk.ffhepm,peng rmi. enB,luycen with wasumlheir sole cnmpmsadinn.
will dothework, ander be Comment
mendedo Law
Tato.Business
iL 3 m and Professions Cade: imp oyes theins License Law dues not apply s if owner of
property who builds or improves t such i, and who does such t into himself or Nnwgh
his own employees. provided this such impmvemenn art mI intended or offered for
wie, IL however, the buildingimprovement is sold within one year dcompinion, the
owacrhuilcler will have The burden of proving Ilam he did not build nil improve for pur-
pom of saleJ.
I, as owner of the property, am exclusively contracting with licensed contractorsto
construct the project (Sec 7(W. Business and Prolessu ns C dc:) He Contractor's La-
st law cases not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such pmjens with a contraaods) licensed pursuant to the Contractors
License Law.
I am exempt under Sec. . B K P C for This reason
Daft
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declarations:
n 1 Imvc and will m%imnin u CenlOe%m of Consent to sell-insum for Worker's Compen-
sation, as provided for by Section 37W of the Labor Code, for the performance of he
work far which this permit is issued.
❑ I have and will mountain W(rkcd Compensminn Irourunee, ;is trained by Section
3700 of the Labor Code, for the prome ecce of The work for both this permit is issued.
My Worker. Compensation Insurance caner and Policy number are:
Caries Policy No.
CER'I'IIBCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wGam recd nal M cun,pined if the permit N fur one Imndred dollars ($ LIN))
or leo.)
I certify that in the performance of the work for which this pentdd is insued,l shall
nal c"ploy
un person conn n 411, { y:uv—�t;fe( I,uthe Wnrkerr.'Cumpcn-
O z salinn Laws o C' lit ,a. D, (/whit f l
z Applicant _ '
NOTICE To A PLICANT: If, allon making this Cemificlac of Exemption, you should
1•' h become mbjea to Ne Workers Compcnsalim previsions of Ne Lahr CWe, you mind
S forthwith comply with such provisions or this permit shall rte deemed revoked.
aQ
CONSTRUCTION LENDING AGENCY
U O Ihereby whichaffirm Nottheseissue (See 30 lending agency for the peHormance of
0 Newos nor which Nis pumif lx issued lScc.3W7, Civ. t'.)
O U Leaders Name
i"
Leaders AJtlrtnn
I
HQ. anee tbm Imvc ilial this appnc our and sure that The %hove of staid, is
N building I agree ur comply with WI city and county natives oft and sem laws relining a QTY,
Uz abovengronmmGiomand hereby enthrone representatives ofNiscity menmrupon the
above -(We) gord ne
for imnifyan keep cs.
(We) agree m save, and expenses
and kap M1ay in an the CiIY of Cupertino eguim,
aabilitics.judgmeme cost and expenses which may in any way acerae aguinsn wit Cily
4ye,cc of ,lac ung grnnof anis pamit,
APPLrJNNT I�SI&NDS AND WILL COMPLY WITH ALL NON -POINT
« IIA%ABDOUS MATERIAI.S DISCLOSURE
Will the applicant or future holding occupant store or handle hazardous material
as defined by the Cupenin, Municipal Code, Chapter 9.12, and the Health and Safety
Code Section 2553200'! r, o
E] Yea tk
Will the applicant or li%tue building weapon use equipment or devices which
emit b crandous air contaminants as defined by the Bay Arca Air Quality Management
District'
❑Yes YNo
1 have read the hazardous materials requirements under Chapter 695 of the Cali -
forms I{eu «r Safety CWe, Sections 2550L5. 25533 and 25534. 1 understand In., il'fhe
builNnl� have a tenant. that it is my responsibility ur notify the occupant
oOhy1% der he met prior no issuance of a Cenjlitmeoff Ocraine,
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UPTOYW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TF,MR METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTIC
OITTLE'rS - SWITCHES - FIXT
NEW RESIDENTIAL ELECT
0
?-23
X02/
BUILDING PERMIT INFO
BL ELECT
J ❑
PLUMB MECH
❑ ❑
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE -PIPIT
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ClSWIMMING POOLS
❑ BATH REMODEL1REPAIR C3 DEMOLITION
❑ OTHER
'LIP C
COMMERCIW
[I NEW BLDG/ADDITION
❑TENANT
IMPROVEMENT
❑ OTHER
ID DEMOLITION
❑ FOOD SERVICE
PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN Fr VENT- WATER (EA)
BACK FLOW FRUIT= DEVICE
OR A INS- FLOOR. ROOF AREA. COND,
FIXTURES - PER TRAP
GAS -E\. SYSTEM -I INC. 4 OUTLETS
GAS - FTA. SYSTEM -OVER 4 (EA)
GREASEBNDUSTRL WASTE INTERCEPTOR
GR17ASE'I'RAP
SEWER - SANITARY -STORM EA. 200 IT.
WATER HEATER W/VENTELE( flu
WATER SYSTEMTIREATING
WATER SERVICE
NEW RESIDENTIAL PLMIf. SQ. FT.
TOTAL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10,00 CFM)
EXHAUST HOOD(W/DUCO
11I7ATING UNIT (TO 101 BTU)
HEATING UNIT (OVER 100,000 FIT U)
VENTILATION FAN (SINGLE Rl IU)
BOILER -COMP OHP OR W.WB If
BOILER - COMP (OVER 1W." BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ, PT.
TOTAL:
OFFICE
FEE
SQ, FT. FLOOR AREA LSQ, I
VALUATION
!^'
STORIE TYPE. CONSTRU
OCC. GROUT' AP
6
BUILDING DIVISION FEES
PLANCHECK PEE
ENERGY HE
GRADING FEE
SOILS FEE
PAID �_—
ca I
1I u TOTAL: I
BU ULNG FEE
SEI E
El.li � Piili
PLUM EE
MECH CALFEE
CONSTRUCTIONT %
HDUMNG MUHG IO .E
PAID
Dam Receipt«
TOTAL'.
ISSUANCE DATE
ISSUED BY: ` p