S 2020 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BAL T PEN ONLY
CITY OF CUPERTINO RDILDIN(:-ELI:f.'1'RICAhIII Pli@Irlfl No. ^O^ O
BUILDING DIVISION APPIACATION/PER PLUMBING.-, . .HArv1cAl V\ L L
I OJF I1:NTI4' O
BUILDING ADI ESS: SANITARY NO. APPLICATION SUBMITTAL IIAI'E
i9N ! Vi�� co c NO 2 _ 29
OWN ;y NAM � ONEO CON'I'tACTOII'g NAMl1: � LIC NO:�
L/�/�yaar) !/O NIC CON'I'R01,8
Alt TIIIiNGINIiBR: M hICNO: AD HP`$ wF,N•�.U4 Ry 6 ❑
rfrACT: !tom PHONE: ✓C BUILDING PERMIT INFO ,
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Qjry t' � ELIiCTRIC PERMIT FEE
1 hereby affirm rhm 1 am ficemad under provisions,,Chapters femmnenemg JOB DESCRIPTION
M�Z lit Section 70x0)of Divl,C 3arthe Badness an PPro o Cde,andmy license is RESIDENTIAL
+100 . PERMIT'ISSUANCE
,= in full forceand elect. /'1 - -/ G��-✓ ❑SIbWL ❑KITCHEN ItEMOD1!1.,.
QUU License Cl az4 ti.,..ry�-��'✓✓✓ Lica Oe (Q7 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
tF�a Date /7/-3��'�'� Comrmmr
All DI'1'ECI"S DECLARA'I ION ❑MUM[-UNIT ❑S'I'RUCTURN.
zo'�z Iundercmnd my plamshull bemed as public record, IpNLLS MODIFICATION
uZ-a UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1-yfW Licensed Pn I .....ral 201-d)(NIAMPS IMPROVEMENT E]SWIMMING POOLS
J
OWNER-BUILDER DECLARATION 1OVER I XXJ El BATH REMODHLJRHPAIR El DEMOLITION
K W 6 I hereh uMon that 1 am exempt from rhe Comractor's License law for the
O L U following reason.(Se,inn 703 1 5,Bnineas and Professions Code:Any city orcomay SIGNS ELECTRICAL EIOTHER
31y,ti which residues a permit a,crmuru,,alcor,improve,demol'Ish,er mpair any amemre
1-'LL'0g prior its issuance,also require%the applicant for such peit w file a sigaedsm¢mem SPECIAL CIRCUIT/MISC.
Wynm,
thin he is)cued pursuant to the provisions ofthe Conductors License Law(Chapter q
fano m(commencing with Sevin.7000)of Division 3 m me Baomr,sand Probe...cns Code)olTEMP METER OR POLE INST. COMMERCIAL:
6 a:ca
C 'hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ❑DIiMOLITION
ca-.h Section 7031.5 by unyaildicunl lir a pend',ubjec¢,he applicant ma civil penalty of POW17R DEVICESE. ❑TIiNANT ❑FOODSERVICE
oro room Chun live hundred della,,0$510).
E Z N IMPROVEMENT
�9pQ ❑ Lo the woref'M poilivirty, with wages d((itstheir(ec.compensation, SWIMMING POOL ELECTRIC
t.I dr,Jnficwna,Cosec stat Cureisnots Lievals,Laed(it time,
((it sale p,lyo all lininch El OTHER
L ra•' and
property
who builds
improves
Contractors License Low soca net apply to if owner of OUTLI!'T$-SWIT'CIII?S-PIX'I'1JRES
his oan who build or sided tha t such i,and who does such tints himself fferedthrough
his own trainer,
provided that such improvements ore net in' 't or offered for NEW RESIDENTIAL EhEITR SQ FI'.
sale.r imildevuq ll have the burden
n ollar sung Chadd within one yid„fm,mplet inn,Chu SQ,IrP.FLOOR ARRA $ISQ.PI'.
crvhdiltler will have the harden of proving Thal M1e did not build nr impnwc for par
pass ofsale.). TOTAL
I,as owner of the pmpeny,nm excursively ennllecting with licensed cnntmcmmo
mI
, atrvn the props,(Sec.7EFFE Business and Professions Code.)The Convectors Li. -
eeLawdoesnotupplytoanownerufpropenywhobuildsorimproves therm,and QTY. PLUMBING PERMIT FEE
cerise
lm nrrecis larsech pmUeco with acentmcurs')licem,l Pn,,rant to lbu Gm focus's
License Law, FERMII F ISSUANCE
❑I an exempt under Sm ,H&P C for his reason
Owner Date ALTER-DRAIN&.VI3NT-WAIT ITR EPA) VAI.UA'1'ION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hernhy affirm a nder penalty firperjuryensot he following deelamtionc.
❑Ihave and will maintain a Certificate of Comenl to sell-insure for Worker's Cnmpen. DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONST BLOC I'ION
sminn,as Provided for by Section 3700of the"Ease Coal fonhe perfmmare,of the
f�lar is lch this permit is insucd. FIX'T'URES-PERI'RAP -
gl have and will maintain Workers Clnrpe„aotiun Insurance,na mcfared by Sectlull
3 ofthe labor Code,for the performanre of the wark fforrpwhhiiehthis permit is issued, GAS-ITA.SYSTEM-I INCA DUE LETS DEC.GROUT' APES
Ca Werke/&Cl,r9l,� nn ly_ ygeVanierRtl cy NnY[�/�u 5,
Carrier: LAC L'OM �N_�_-- GAS-BA SYS'I'hMOVIiR4[I!A)
CEKI'IPICATE Up EXEMPTION FROM WORKERS' if
COMPENSA'T'ION INSURANCE GREASE YINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(Thin R'c'tirn nrnd n,hcunmpleatiliRhc permit is Entire hundred Jnllu,,(S1I0) GREASE TRAP
ar lcaaJ PLANCHECK FEL'
I certify that in the perfacrancenl the work to, hi,1 is Permit is issued.Ishull SEWER-SANITARY-STORM HA.21X1IT
nal culPloy any peram,in any summer Sn as to become ville,t to the Wofkerd Comp„- FJJURGY Fla;
Oz
sminn Laws of Cnlifnmia.Dam A LR HEATHER WAINT/EE,-
Applicant GRADING EEE
q NO[LE TO AFPLICAN'f.Ir,after making'Ili'CcniGr a(of Exeltual a.yraIli I L 1 t SYS'"EM!'REA1 INC.,
7 .WPI 1, I r^r tm�l•.. SOIl9 FEE
E"I bemnv subject m the Worked Cnmpcnwlinn pnrvuinns rI (he L'Ma Coda y0ino
�+ Q forthwith comply w Ih such provisions nr tit Pe qidml M teem 1 nkd
e . ?(( pTERtSERVICF_r +tri
7 Z CONSTRI)QT10N LENDING AGENCY r_0 4'' �t NIW RI SIDTNTIAL I I MB SQ.I 1'. PFID
V Iherebyaifr9P ,Rcrcu�nwv,n.hall henry fee. pert rmange o7 .,s ......... Irate RtteiPta
thewerkfnrwhichm ls. l(Sec.N 7,Ci ,Fil 'v ''.%�• ,
IL F 1-1-, Nmre r�` �. YS ,T •• TOTAL:
L) Lenders Address _r f I) -, TOTAL:
dI celily that 11 rV>a)Ih eP)Et t dsha tb,fineadinhatin,flom is BUILDING FEE
0 correct Iagrec,o c... IanWWrrlh ill'g?'ntc. my d' nrua a.” ]ws mining MP.CHANI_CAL PERMIP, NEE
V Z building crnnrvcdon. d lkRby au(huraereprcxrMShra%nf Ntsmt�(Mcrimr„mrlt ,, ,., . , , 1�r SEISMIC IIiE
eMwo-lnentinned prnl,<ny fnf[�.ppl�pyGM1i pw',\Ivl 1..L Sp.�, )' §§\y��C)J PERMIT ISSIJANC1i
(We)agmc,,Sova,inNvlfi fY�ndJ'keep hnpnl�Q'he CittN U. �Iieagaind P.LI!C'IHIC
liahilitics.judgmems,costs anJ ra�,K,%7eS w�bidin_ypinff��any\�pc cagainSl said Cily 1(�yTE_RORAU ITCH. e_ PLUMBING
APP in consequence
UNDERS'T'Aof the NDS "Lv7)�WIL M.UYI WITH ALI,NO T _� .� f` ��
AI DLING UNI'I'('IYJ 10,000CF10) MECHANICAL LI?
501 CE REGUTA'UONS.
set I 1 NUI!1 IT.LQVER.I11,p00 CPM)w:-,a•r rrve�.;.ar..W,Z"IsfSTRUCTIO 'LAX
Signamm rfAppllcaMCumm,ur \ D EX .'f IIOOD(W/DUCT) HOUSING MITI ION ILC 00
IIA'LARDOUS M LS DISCLOSURE /�
Will lherpplinuu or linnet M1uildl,n occ pnm xWP�TX�'�(•tQan to wous miar�1l i1�
a%defined by the Cupertino Municipal Cde.Cp��a�ra���}1V.turd Ili I zRh as
Code,Section 215321n)? StYJ HEATING UNLI'(OVER HEl BTU)
O Yes ON. VF.N"ULATION FAN isINGLI!ItPSID) PAIII
. Dat 'e Ree
Will the applicum or future building m(Ilk��plri eyvipmem or devices which gOg.l!R-COMP CHIP OR]FEAR)ETU)
emit hammed,mr In. in maims as dcfmcd by uy Am Air Odnlity MancEn den C-N
Dishin?
❑Vcs ON. ROILER-COMP(OVER 100.010 BTU) (J
I have mad the h—emus materials requiceirri under Chapter 695 111'the Cali- AIR CONDI'I'I(INER ISSUANCE DRIB
firman Heath&Safety Code,Sections 25505:25533 and 25534.1 understand that if the NEW BESIDES RAL MECH. SQ.FE
bulldingdoennolcurrcnllyhnvealentmL'hnti,k ni,respon taidyle n,ify the sec I
w'dw ri gx
wrenms which con,ho met prior to ko a we of Certificate of Certificaof Oc,lparcy.
Owner or authuriul unci' Dam TOTAL: ISSUED BY
OFFICE