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CITYO CCUPERTINO BUILISING- ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MI!CIIANICAL
BUILDING PRQIEC'I' IDEN'1'Ih'ICATION
r^
PH M11 NO O V 17
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Z
BUILDINGAUf�LSS: �
S/J
'
SANITARY NO.
APPLICATION SUBMI'IIAL IIA'I'I
O NF: R" NAME' ?HUN 1
t
CO R O 'S AMC: LIC NO'.
t
NIC
❑
CONT ROLst
(I ARCH E /EgNG1T Ej� l T I�N� �
iYLL
A URE . !9
CONTACT: PHONE:
1
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❑Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG EiI- PLUMB MECH
LICCEENSED CCONTR`ACTOR'S DECLARATION
1 hcrehy alfiam Ihm 1 em licensed under provisions of Chapter 9 (asmmencing
with Section 7L0(d of Dlvislon 3 of l m Buslnesa and Pro essiaa Coate, and my license is
in full fia.mrl cReel,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KL' 1'CHEN REMODEL
PERMIT ISSUANCE
APPLIANCES-RIESIDENUAL
PANELS
UP T02p0 AMPS
I License Cl.ss Lica—ate � —I
Dam Con wcmr
ARCHITECTS DECLARATION
I understand my plans shall he used as PnhlwovoNs
C1 ADDITION ❑ PLUMBING RE -PIPE
RAL
❑ MUCITUNIT ❑ MODIFICATIONSTRUCT
CHIMNEY
[I INTERIOR ❑CHIMNIiY RIiPAIk
IMPROVEMENT []SWIMM INC, POOLS
l.icensrd Prmeaional
201-100NIAMPS
OWNER -BUILDER DECLARA'I']ON
I hereby nflina that I am exempt from the Contractor's License Law for the
I fallowing reason (Section 2031.5, Busanc.. mad Professions Code: Any city gr county
[I BATH REMODEVRI3PAIR DEMOLITION
❑ OTHER
OVh:R IfNNI AMPS
SIGNS EI,EC'I RICAL
i which requires a permit in construct, rima, improve, demat ish, or repair any structure
1 prim It, it, screrc,ohnat,air,thenpplicanl forsuch perming EhI a signed amtemaR
that he is licensed pursuaal to the provdal ins of the Commetnrb l0cenm Law (Chapter 9
(conmnearing with Sredmt700)IFINva.ir3nl' the Basiocxsand Pmrcaslone Code)...
( (hal he is exampl Ihereften t and the hods lir the alleged exemption. Any vlolminn of
Section ]031.5 by may applicamfor a permit subjects the applicant to a civil penallyor
SPECIAL CIRCUIT/MISC.
TEM It M INE R OR POLIS I NS' I'.
COMMERCIAL, eA'
[:1 NEW BLDG/ADDITION ❑ DEMOI.L'I ION
El TENANT ❑FOODSLRVICI?
POWER DEVICE. is,
s not ..or than Bre hundred dollars l$51118.
C] L as owner oflhe pmpeny, or my employees with wages as their sole compensation,
will do the work, unit the structure is not intended or alloyed for aide (Sec. WWI Business
i and Prolbasions Code: no, Contractors License Law does not apply to an owner of
IMPROVEMENT
OTHER
❑ OTHER
SWIMMING POOL ELECT RIC
OUTLETS - SWI 'I'CUES - FIXTURE S
property who builds or impn)ves thereon, and whir does such work himself or through
his awn employees, provided that such improvements are not mended or offered for
sale. If,however. the building or improvement is sold within one year ofcompletion,the
NEW RESIDENTIAL ELT:CI'R SQ 17E
SQ. FT. FLOOR AREA
VSQ. F -n
wnerhilder will hove the burden of proving that he dad not builderimprove far p e,
IOTA L.
poseof mleJ.
1, owner of the property, am exclusively contracting with licensed contractors to
-7 1.
I�
P� Ay ' }�
N
QTY. PLUMBING PERMIT FEF.
consumer the project (Sec. 71111, Business and Professions Cale:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
V
���
who contracts far such projects with a contractorho licensed paramount to the Contractors
License Law.
❑ I am exempt under Sec. . B & P C for this minv
8 If�
gry,/1
rrrsTTTr....{{//
PERMIT ISSUANCE
ALTER - DRAIN At WATER (EA)
Owner
(' N
UC
Cnllpitu
WORKER'S COMPENSATION DECLARATION
BACKFLOW PROTECT DEVICE
1 hereby eRrm uncle, penalty of perjury one of the following daliand.r s:
I]race and will maintain aCcnificutcof Conunnn self-insurc far Workers Compete-
DRAINS- FLOOR; R(IUF, AREA. COND
STORIES
TYPE CONSTR UC7GON
cation, as provided for by Section 32W of the Labor Cert. franc performance of the
work for which this peril is issued.
FIXTURES - PER TRAP
d I have and will maintain Workers Compensation Insurance, as required by Section'
3]00ofthe Lehr GNe,for the prtlbameceofthr work forwhich this permit is issued.
GAS-EA.SYSTEM-1 INT OUT1.P S
OCCGROUP
MIN
GAS-EA.SYSTEM-O ER '
CarrW�rkcf,51Crnt. r licylial
c.fi?MPTION PROM
GREASFJINDUS "I'li N'I'[zRC]zlllf R
IFICAr: p WORIre
✓<`Ll� COMPENSATION INSURANCE
. BUILDING DIVISION FEES
(This stcaon need me he emoplefed if the pernh is farina, hundred dollars($100)
or loss.)
REASE TN
PI,ANCHECK PIi13
I certify that in the perliannmce(ilthe work for which this pertain is issued,I shall
not employ any person in any summer m as In hecoom suhjc,i m the Workers' Compete-
SEWI t -SAND -S' )RM .2 1'I
iN131tOY PEE
WA'fEHEATER 1N'I'IIB.I!.'lt
WATER. STFM/ HE
WATER SF. N ICF
GRADING PEE
salon Laws of California. Data
Appliasnl I
3 NOHCHTO APPLICAN It If, after making Ibis Cenifimam of Exemption, you should
hecome subject to the Workers Compenside m provisions of the labor Code, you must
forthwith comply win such poo,kjons ter this permit shot] M1e deemed rem,k,d.
SOILS PEE
CONSTRUCTION LENDING AGENCY
I herebyoffirm that is a construction lending agency far the performance of
+ the work for which this permit is issued tare. 3097. Civ. C.)
•
Lenders Name-
PAID
D: R eilu
TGI'AI.:
NEW SI 1'IAh
LMH. SQR"I'.
(YI
Lender's Address
BUILD( G
I rectify that I have read this application and pate that the above information is
SEISMIC '
1 correct.i agree tea comply with all city and county ordinances and state laws relating tat
building construction, and hereby authmine representatives of this city to enter upon the
+ abovo-mentioned property foriuspection pmposes!s
(WO agree to save, indemnify and keep harmless the City of Cupertino against
QTY. MECHANICAL PER
PERMIT ISSUANCE
ELECT CFEE
PLUMBING
Iiabilities,judgmai costs and expenses which may in any way acerae against said City
. consequenceI f��IIgRSTANDS granting of this p WILL
APPLI ANT UFl)ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU c RF.GULAT /y Ar
ALTERORADDTOMECH.
AIR HANDLING UNIT (10 ]II,OXN)CFM)
MECHANICAL F[
AIR HANDLING UNIT LOVER III,INN]CF
CONSTRULTIONT
OY /"f/
'/y-t�/
S' n re PslpplicuMContractor Date
EXHAUS'THOOD(W/DUCD
HOUSING MITIGATION THE
HAZARDOUS MATHRIAl S DISCLOSURE
HEATING UNIT GO 100,001 B' 1' U)
Vll the applicant or future building occupant sloe or handle hareomms material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cole. Section 25532(.)?
HEATING UNIT (OVER 10,1001 BTI)
VENTILATION FAN (SINGLE RISS I D)
E] yes E] No
PAID
Date Receipt p
BOILER - COMP (3131' OR Baynt0 BTU)
Will the applicant or future building occupant use equipment or devices which
eadt hamNous gar contaminations defined by the Bay Arca Air Quality Management
TOTAL:
District?
El 'As ❑Nn
BOILER - COMP (OVER 101,000 BTU)
AIR CONDI 'I'IONEIt
I have avid the hmardans materials mopdrctmeou under Chapter 695 ofthe CII-
I�SSS`\\U�A�NCEEE DDs+AATi�I��_�
NEW RI?SIUIINT'IAI. M13CI I. SQ. PI'.
25533 amp 25534.1 understand Nm if the
Sudety Coda, Section,. 53 12.55 1
fomite Health old, Jr.
2Ihm
l4.
n rre1. dea i h is rcs m notify (M1e occupant
building doth sol ay n
orthe rvqulmments which const he ma prior Io @.wince tel' n Ccnlfwtc of Occupancy.
V
ISSUED BY.
'TOTAL'
Owner or ammanod agent Date
OFFICE