99120030TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTIN^ nuu.Dmc - ha.RCrRlcnl.
BUILDING DIVISION
ADDRESS:
APPLICATION/I'ERMIT
rl
C L, xy-+i ril-c
0
❑ Cmendtant Fees Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARAII "'Cry.
1 hereby affirm that I am licenced under provisions of Chupler'J (commencing
with Sectien'/(H(nof Uivi,mr3ofthe Business and Profcmlins C,dc,.. my license is
in full have and effect.
License Class Lite
a ARCHITECTS DECLARATION
F- H Z I understand my plans shall rte used as public records
OZ=—0
F 4 t W Licensed professional
OWNER -BUILDER DECLARATION
C) G 1 hereby carrot that 1 am exempt from the Contractor'sL.icensc law for the
�3aIµJlow g IS f 10315 B d1 f Code: Any city or cnunry
yhuh arigine, a fenionu, emalficall.❑ p dentail"Ir 11 ey I'
^u'0 prom I al - requires In ppl' If M1fc 'n
m¢I� thane IP tt m p - of C I t sI .eI ( pm
isld� (eon nenclhgwth Section 701X0 of Dis on 3 til lire Buonu'a. ul
d ¢%o
her he is exempt heirloom and the hells for Iltc alleged cxenquinit Any vi( nam of
a m
„m Section 11111.5 hY anY upplicam lyra permit sanfecls the applic:aaI peva of
hun li
not nem Ive hundred dollars ($500).
SSG �I. as iabor of the property, Or my employees wish wages in their soki1'L®s
F- will do the work. and thcswemre is not intended or offered for
Wm aha Pmfessi'ms Code: The Conlmctlrs License law d«x not apply to an more, sof
property who builds or improves thereon. and who m,es wen w If h
his own employees, provided that such impmvememx are nm i o
-le.If. beat -r, he buildingor irepmvcmem is sold within one n
ser -builder will have the burden of proving that he JiJ not b
h+rte s.if esown. nr r -
r of the prnpcny, am exclusively contracting with licensed contractors w
construct the projst (See ]IWi. Basins, and Pru esslonx Cock) The Contractor's La -
Cruse [,use dues not apply to an owner of property who buddxor improvex thereon, and QTY.
who contracts fir such projects with a contra,fin(M licensed lit, fit wtee Conaacmts
LicenseLaw,
0 I m ex..np..rolet 5uc ------------ 717— . It & P C for this reason
(ELECTRIC PERMIT IPEE
PERMITISSUANCE
APPLIANCIiS - RESIDENTIAL
PANELS
UP TO 200 A ML'S
201-11Y0AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
Dale
It,, lilsix WORKER'S COMPENSATIONDICCLANATI(')N
1 hemhy ffirm under penalty of perjury one of the Ibllowing declarations:
I have and will nuinmin a Cer ifiene of Consent o self -insure for Workers Coni
73700
en, as provided Ea by Secret, 37M of the Labor Cote. for the performance of the
rk for which this permit ix issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
ofthe Latimen Code, fir the ferntative Of the work fm which Ibis permit is issued.
y Worker's Compensation Insurance carrier and Policy number am:
me': Policy Ni.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
UTiasection need roti be completed ifthe permit is for one hundred Jnllers ($100)
amity that
cr in the pby camwce of Ise work inewhich this permit is issued, l shall
mnpiny any person in any manoarsu as Ii naaunho suqivat to tiro Wnrkera' Cnmpero
"Z salion lawn 0 California. Date
Z 2 APPlicant 1
szs� NO'UCIi TOAPPLICAN'p 1L afermuking this Ctiificmeef Exemption, you should
a, bacons.object a, the Workcis Compcnsutio I provisine, of he LuM,r, Crde, you must
fanhwith comply with such Pmvnirns o' his (email shall her dimmed revoked.
d
7z CONS0NLENUINGAGENCY
U O Ihercny uffinn that memmiss3at ronflmetion lending agency file the performance of
W r the work for which this paced is i...0 Ncv. 3(M)1, Civ. C.)
C) U Leander', Nance
LU Lender's AdJeess
G 1 certify Lha 1 have read this application and state that he aM,ve infemxtion is
LHs h cumo. I agree Is comply with all city and county ordinances and state laws relating to QTY.
UZ bmidmgearswct 1, and hereby authorize representatives of this city n, enter up,mme
alarve-dnendnned property for inspection purpose'.
(We) agree mauve. InJmnnily and keel hvnnlay the City of Cupertino against
demi li fas,'palgnmms, conte and expenses which inuy In troy way acerae ugai est said City
I,, ant
xcgnence of the gnmtirg of this pee-ona.
API'LICAN'I' 11NDIERS'I'ANDS AND WILT. COMPLY WI'I'll ALT, NON .1101 N'f
SOIL RCE RFG 01.Kl'IONS.
.e _.__..
IIALARDOUS MATERIALS DISCLOSURE andl
Will the a Culler or future building e. Chapter
tore nr nwdk h eaNnusd Safety
ta
as defined by the Cupertino Municipal Cade. Ckapher 9.12, wJ the Health and Safety
Cock. Section 25532(a)°
'❑Yca ❑No
Will the applicant or future building tarragon use equipment or devices which
emir htmedo- air contaminant, as defined by the Buy Arca Air Quality Mmagement
District!
❑Ycs ❑No
I have rend the hecanlous materials escrucmcros under Chapter 6.95 of the Can-
finees IIea11h R Safety Code. Sections 25505, 25533 and 25536.1 ruderoand that d the
huiking doesbut c,in anJy have stanunt, deal it is'tidy ru..... hilily Io ramify he occup:ml
Mail h road he recalrior it, issuance o1' a Cenilicate of Occepanay.
PLUMBING PERMIT
PERMITISSUANCE
ALTER - DRAIN h VI'.N'I - WATER (IIA)
RACK FLOW PROfEC'E DEVICE
DRAINS- FLOOR. ROOF.AREA, COND.
FIXTURES - PER 'rRAP
GAS -IEA. SYSTr:M.I INC. q OUTLETS
GAS- EA. SYSTEM OVER 4 (EA)
GRF.ASEANDUS HU, WASTE INTERCEPTOR
CREASE TRAP
SE W IEk - SANITARY - STORM F.A. 200 Fr.
WATER II VA] 17H WIVENfTLECTR
WAD R SYS'1'EM/IBEAnNG
WAI ITR SERVICE
NEW RISIDENTIALPLMB. SQ. En
TOTAL
MECHANICAL PERMIT
PERMIT ISSUANCE
AhTI:R OH ADI) Ti) MIiCH.
AIR I IANDIA NO UNIT (10 1 qq0 CFM))
AIR DANDLING UNIT' (OVER 10,000 CFM)
EXIIAUS'I IICOD (W/DLJCI )
HEATING UNIT ('Ix) 101.000 OTU)
MEATI NO UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE. RESID)
BOILER -COMP CUIP OR 110,000 BTU)
BOILER - COM P(OVER 100!000 BTU)
AIR C(INl: "[ UNER
NEW kESDEN'I IAI, MECIL Sp. I4'.
TOTAL:
OFFICE
10-
PFJ
DING PERMIT INFO
LECs PLUMB MECII
El w/ ❑
JOB DESUKI V I ION
RESIDENTIAL:
❑ SFDWL
❑ KITCHEN RIrNODEL
❑ADDITION
El PLUMBING RE -PIPIT
❑NIULTI-UNIT
❑STRUCfURAI.
MODIFICATION
[I INTERIOR
[I CHIMNEY REPAIR
El SWIMMING POOLS
''I'MPPROVEMENT
�an�
L''�H REMODEIIRF.PAIR ❑DIEMOLI'PON
❑ OTHER
COMMERCIAL
❑NEWBLDG/ADDITION ❑DIEMOLI'HON
ED HNANT ❑FOOD Sit VICE
I, ROVF.MENT
T IES
SO. . FL $/sQ' lel'.
5y
FEE
VALIJAI'BIN
poO
STORIE' 'TYPE CONS' I'RUCTIO
OCC. CROUP � � A��
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEE
GRADING i'EE
SOILS ITB
PAID
17mc Ric, jn p _
Int //1�TG'I'nL�
BUILDIN 1TW II
FEE SEISMIC �G'r DEC
FL VEE
PLUMBIh GFEE
MECHANIC..I�I9T--'
CONSTRUCTION "fAX
HOUSING MITIGATION ITE
PAID
Date Receipt e
TOVA.: +O
ISSUANCE DATE
/
2, -
ISSUED
ISSUED BY: ' s