30923APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO
G
SPECIAL IRC MISC.
❑ADDITION
BUILDING -ELECTRICAL
UMULTI-UNIT
PERMIT NO. ^
"LJ
BUILDING DIVISION
SWIMMING VL EL CfR
APPLICATION/PERMIT
OUTLETS -S C -FI VRES
PLUMB NO. MECHANICAL
NEW RESIDENTIAL EC
yJ {J
30923 Jj O 93
❑ OTHER
SOILS F
FEE
TOTAI
BUILDING PRO,JEUP IDRMpIFICAq'ION
PAID
Date
PIiRMIT ISSU ICE
BUILDING ADDRESS:
ALTER ATER(CA)
BACK FLOW PROI'IiC . E
/� i -
SANITARY NO.
APPLICATION SUBMITTAL DATE.
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SEISMIC PLC
1`\ -Tl /SIN. VK CSJ,
I
ELECfRICMI
OW RS NAME:
r
I ZONE:
CONTRACT' OR
'S NAME: LIC NO:
N/C
.--'CONTROL#
i
�C)ly[ECQ[ NE
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LIC NO;
ADDRESS:
coNTAcc
PHONE:
IBUILDING
Receipt It
PERMTT INFO
I hereby.ffirm Nat I ore IicenseA undm pmvisione of Chvpter 9 (enmmendag
with Section7m)( rDw n3of the Businiit Professions CpJe, and my licence is
in full farce and effect. Q 731V1
License Class Lic.#
late Con
DECIonDEC
RCHITF.CFS LAR _
1 understand my plans shall be used as pub re
un s
Licemed Professional
OWNER -BUILDER DECLARATION -
I hereby affirm that 1 um exempt from the Contractor's License Law for the
following reason (Section 7831.5, Business and Pmfessinns Code: Any city nr county
which scquires a permit to consumer, alter, impose, demolish, or repair any euuemre
prior to its issuance, also requites the applicant for such penniuo file a signal statement
Nat he is licensed pursuant to the previsions of the Cnmmcmts License Law (Chapter,9
(commencing with Section 7000) of Division 3 at the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 1831.5 by any applicant for a Permit subjects the applicant to a civil pemby of
not more than five hundred dollen 05108.
FII. m owner of the propeny, or my employees with wages as their sole compcnsmion,
will do the work, and the structure is not intended or Offered for sale (Sec. Wt14, Business
and Prafcssio n, Cale: The Commetorts License Law Jots not apply to an owner of
property who builds or improves Nercon, and who does such work himself or through
his own employees, provided that such improvements am not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner-huilder will have the burden of proving that be did not build or improve for pur-
awn
pouosrete
❑ I, acttheowner of ct (Seeperty am exclusivelynd contracting with Beene Ci contractors m
Li-
cconstame
Law
the project (Sen o an owner Buodcs
and Pnal'eno bri Gari The Cs thereon, nd
c u Law dace not apply m an owner of pmpeny who builds or improves thereon, and
who s, Lactsfor mchp jeers with acontrazmr(s)licensed pursonnno the Comrncwts
1"icense haw. '
❑ I..I exempt reader Sec. B& P C for this reason
Owner Date
WORKER'S COMPHNSAI ON DECLARATION
1 hereby affirm under Penalty of perjury one of me following declarations:
6 1 have and will maintain a Certificate ofConsen to self -inure for Worke's Comped
cation, as Provided for by Section 39110 Of the Lnhor Calc, on, he.parformnnec u
work far which this permit is issued
El 1 have and will maintain Worker's Compensation Insurance, as required by Section
3100 of the Labor Code, for the performance Of the work for which this permit is issued.
My Workers Compensation Inumnce carver and Policy number arc:
Cartier. Policy No.:
CF.RTIFICA'1'E OF I"XEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not becomplet W ifthe permit is fomne hundrW dollmx (SI00)
or less.)
I ceni fy that in thggerommnce of the work for which this Meront is issued, l shall
❑ Consultant Fees Paid by Applicant (Initial)
QTY ELECFRICPERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
/PANELS
UPT0200AMPS T 7
oat emphay any pe try m. es to epntnes�hjgl m Workers' Cmnpen-
O,� salon Lawson
O Applicum C
h NCUCI: ��PL�NT: IL afmr nwking @is C. ..lime of Iisno'nion, you nhouW
a ; become subject n the Worker's Compensation provisions of the Later Code, you must
W4 forthwith comply withwch providinsor Nis famatshall he deemed mvoked.
as Q
Z CONS I'RUGI'[ON LENDING AGENCY '
U O I hcrehyaffrtm that he.iso constmcuon lendingagency far he perfmoscrexof
Fthe work for which this permit Is Issuel (Sec. 3091. Co. C)
U Lenders Nome
"iLenders Address
y 1 certify Nat 1 have read Nis application and stem ma the above infmmmion is
n.t V) comen I agree to comply with all city ana county onlimmces and stoic laws relating to QTY.
U% building conswclim, and hemby authorize representatives of this city to enter upon the
abovcmemianed property for inspection purposes
(We) agree ba save, Indemnity and keep harmiess c City of C.Pumn, agaimt
Iimilioes,jari m e", onJ exPcrous which way accrue against said City
inconsequence of acting of mix Pe
APPLICANT ERSTANDS AN PLY WITH ALL NON -POINT
5 L--fiAZARUQQS MAdTRIAIS DISCLOSURL
Will theapplicam or future building orcuram scare orhandle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and he Health and Safety
Code, Section 25532(.)1 �/�
C] yes Ldr+O
kWill the applicant or fmure building occupant use equipment or devices which
it hazardous air concomitants as defined by the Bay Arc. Air Quality Management
Jistricfl
❑Yes [:1 No
1 have reed havudous materials styuimmcnu under Chapter 6.95 of the Cali-
fornia Heolrhmen cry Cale, Sections 25505, 25533 and 25531.1 urdermod tem time
building Joe I currently have d tenant, that It lsmy realvaoiludir,mnmi ry lbarweumin
ofN rs which must be met priono ismaace of. Cenificmc of Occupancy.
SIGNS ELECTRICAL
G
SPECIAL IRC MISC.
❑ADDITION
ILMP.MI? t'OLE INST.
UMULTI-UNIT
POWER DEVICES
ENIiNGY LEC
SWIMMING VL EL CfR
11 INTERIOR
OUTLETS -S C -FI VRES
IMPROVEMENT
NEW RESIDENTIAL EC
SQ IT.
❑ OTHER
SOILS F
FEE
TOTAI
PLUMBING PERMIT
PAID
Date
PIiRMIT ISSU ICE
ALTER ATER(CA)
BACK FLOW PROI'IiC . E
CHAINS - FLOORH .AREA, OND.
BUILDING iE
GAS -EtC SY9iF I NC.4 OUTLETS
GAS -EA,S :MO ,A)
GREASFJI NDUSTR, S'.TNT 'EPTOR
GREASHI
SEWER- SANITARY -. D .A. 20017.
WATER HEATER W/VEM9L•LE
WATER SYSTEMO REA'I'ING
WATER S17RVICE
NEW RESIDENTIAL PLMB. SQ. PI'.
, JOB DESCRIPTION "
RESIDENTIAL'
❑SFDWL
❑KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
UMULTI-UNIT
❑STRUCTURAL
ENIiNGY LEC
MODIFICATION
11 INTERIOR
ID CHIMNEY REPAIR
IMPROVEMENT
SQFL AREA
V/JJ11
0�4
❑ BATH REMODEUREPAIR 0DEMOLITION
❑ OTHER
SOILS F
MECHANICAL PERMIT I FEE
PERMIT ISSUANCE 3t
ALTER Oil ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,001 CFM)
HXHAUS'f HOOD(W/DUCT)
If EATING UNIT UO 108,010 HTU)
HEATING UNIT (OVER 100,1010 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP IMP OR 100B00 [I VU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RP_SIDENTIAL MECH. SQ, pit.
OFFICE
-z�lenn
STORIES TYPECONSTRUCTION
UILI' I
W BLDG/ADDITION
1'ENAW
. IMPROVEMENT
❑ OTHER
❑DEMOLITION
FOOD SERVICE
PLANC�
1 Z
to 0
ENIiNGY LEC
�1
f�
GRAIJIN
SQFL AREA
V/JJ11
0�4
l _
V
VSQ. IT.
LAal_�
SOILS F
FEE
MECHANICAL PERMIT I FEE
PERMIT ISSUANCE 3t
ALTER Oil ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,001 CFM)
HXHAUS'f HOOD(W/DUCT)
If EATING UNIT UO 108,010 HTU)
HEATING UNIT (OVER 100,1010 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP IMP OR 100B00 [I VU)
BOILER - COMP (OVER 100,000 BTU)
AIR CONDITIONER
NEW RP_SIDENTIAL MECH. SQ, pit.
OFFICE
-z�lenn
STORIES TYPECONSTRUCTION
UILI' I
G DIVISION FEE'S
PLANC�
1 Z
ENIiNGY LEC
�1
f�
GRAIJIN
SOILS F
PAID
Date
Receipt#
TOTAL:
BUILDING iE
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SEISMIC PLC
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ELECfRICMI
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O
PLUMBING PER
MECHANICAL FEE
'
-7
0
0
CONSTRUCTIONTAX
HOUSING MITIGATION
FEE
PAID
Date
Receipt It
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