25571)LICANT TO FILL IN INFORMATION WITHIN RED Lit
BU OF CUPE NO
APPLICATION /PERMIT
xuu.nmr. DIVISION SIO slory
N1
I.ICENSFD CONTRACTOR'S DECLARATION
I hereby affirm that Tall' licenud under provisions0f0hapter9(Comnencing with
IO
Section 7000)nf Division 3 of to Business end Prefessions CMe, end my license is in
IF full force and effect.
WUµI Dirense Class '� OLic.N_!!?
,6
Date Contractor_
R HITECTS DECLARAI ds
Ia lunderrand my plans shall be used as public records.
ad
Lmensed Prmcxs'onul -
11 OWNER - BUILDER DECLARATION
F- I hereby affirm that 1 am esempr from the Cromamors License Law for the
w follnwing motion .(Section 7031.5, Business and Professions Cade: Any city or county
which requacs a permit 10 coasts 1, alter, improve, demolish, or repair any structure
perform its issuance, elm requires the midicam forsuch p .IGO file aaigned shimmed
that he is licensed Partner, o the provisions of the Connectors License Law ( Chapter,
Y. 9 (commencing with Section 7") of Division 3 of the Business and professions Code)
m ombahe is exempnhemrem andte basis for the alle gedwoentrwar. Any sioladonof
4 Section 703 IS by any applicant for I permit subjects the applicant to a civil penalty of
C of more than Eve Funded dollars 050%
m n❑ 1, a ownerofthe property, army employees with wages as theirsele compensation,
will do the work, and the strucem is not intended or offered for sale (Seu. 7044. Business
and Professions Code Ew Cenvactm's License Lew does not apply to an owner of
propeny who builds or improves tenon, and who doe, such work himself m through his
t employees, provided that such improvemrnls are nut innendeJ or offered for sale. If,
however, the building or improvement is sold within one year ofcompletion, the owner-
builder will have the burden of proving that he did not build or improve for pumme of
sale.).
❑ 11 as owner of the property, am exclusively contracting with licenud conwmres1.
construct the project (Sec. 7144, Business and Professions Cede:)'[be Contractors
License Law dues not apply le an owner of property who builds or Infamous I i mmad, and
whocomrecv forsuch projects wit a conteccoold licensed purnm nt to the Contractors
License Law.
❑ 1 sm exempt under Sec. , B & P C for dons reason
owner Date
C�Ve WORKMAN COMPENSATION DECLARATION
❑ IM1emhy affirm that l have acenificate ofconsem mselLinsurc,on anifcam of
Workers' Compensation Ineurnnoe or u certified copy thcrwP(Sec.3gIN),Lob C.) which
❑ Cenifed copy is hereby furnished.
�- Cerffied copy is filed with to city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sectimmused rte be completed if the permit is from hundred dollars ($100)
or leas.)
I certify that in the performance of the work for which this permit is issued. I shall
not employ any person in any manner so u to became subject to the Warken'
Z Compensation Laws of CaIlifomia. Date
zNOTICE TO APPLICANT: IL after making this Cenifiwte of Exemption. yousM1OUId
FV) become eubjttt m the Worker's Compensation provisions of the Labor Cal you moat
fort wit comply with such provisions or this pemdl shall be deemed revoked.
a Ca
CONSTRUCTION LENDING AGENCY
'a Thereby. conothalthem is a construction lending agency for the performance of
U Q the work far which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
OLender's Address
U
J
counsel 1 certify that 1 have mould 'his application and amm that the above information is
. I agree to comply wid'all city and county ordinances and state laws relating to
rn build ingconsiruction, andhembyaathodwmpeenm 'ivesofthiscilylomterupnnthe
J 7 above - mentioned pmpery for inspcumn pooperates.
•7 (We) agrce'o save, indemnify and keep hatmlesa to City of Cupertino against
liabilides,judgments, costs and expenses which unayin any way eccme agmust said City
in enmet uenee of the gmnfng of this permit.
Signature of Applicant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
WIII 1M1enpplaard or Rume building oocupan'slum or To cle hararduus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(y7
El Yes Drbo
W ill the aPP1 icant or future building occupant use equipment or devices which emit
hamrleus air contaminant, sea defined by the Bay Area Air Quality Management
Disvid9
❑ Yes X14.
1 have mad the hamrdeas materials requimmenm under Chapter 6.95 of he
California Health & Safety Code, Sections 25505, 25533 and 25534. I underewnd Ihut
if the building does not currently have o Band, that it is my rc5ponsibility to notify the
occupant m the equiremems which must be met prior no issuance oft Cmlficate of
"eras D_ W.. D m 1 1_ n C_C LI
ISE BALL POINT PEN ONLY
oUn:DTNG -Fl,TC rRpf:Ai
PLUMBING - MECIIANICAI,
Iq,OOD ZONE
BUILDING TRITURC'T II)FINTIFICATIIIN
s LOT
CIOR'S NAME: LIC NO:
FF f! =Ar /N6
_
ESS:
FEE SUMMARY
LECPRIC PERMIT
FEE
SUANCE
SANITARY
Y_
APPLIANCES
RECEIPI'q_
AMPS
=�PS.
SCHOOLTAX
Y_
MPS
.
AMPS
PARK FEH
Y
CTRICAL
RRCEIITp
TEMP. METER OR POLE INST.
POWER DEVICES -
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDFNTIAL ELECTR
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN& VENT- WATER (PAT
RACK FLOW PROTECT, DEVICE
DRAINS - FLOOR, ROOF, AREA, COST.
FIXTURES - PER TRAP
GAS - EA. SYSTEN14 INC.4 OUTLETS
GAS - EA. SYSTENLOVER 4(HAT
GRFASFb1NDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA, 200FE
WATER HEATER W /VE1"I'LE .ECfR
WAT17R SYS'IEM/IRGTING
NEW RESIDENTIAL PLMIL SQ, ET.
I MECIIANICALPHRMIT
25571
0
BUILDING PERMIT 1
BLDG ELECT PLUMB
❑ ❑ ❑
FEE
Iq,OOD ZONE
FEE SUMMARY
O IDE';F.S
SANITARY
Y_
RECEIPI'q_
SCHOOLTAX
Y_
RECEIPT p _
PARK FEH
Y
RRCEIITp
BUILDING DIVISION FI
PLANCHECK FEE
GRADING FEE
SOILS ME
ENERGY FEE
PAID
Dole
Rooclp'd
FEE
PERMIT ISSUANCE I "i �
ALTHR OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CITE)
AIR HANDLING UNIT COVER Efort, CFI)
EXHAUST HOLD(W /DUCT)
HEATING UNIT (TO 100,000 HTII)
HEATING UNIT (OVER 10(LIbb kyj Of
VENTILATION FAN (SINf611 RFeun
BOILER - COMP C RIP OR U)0,000 BTU)
BOILER - COMP (OVER 100.000 BTU)
NEW RESIDENTIAL MECI1. SQ. IT,
BUILDING ME
SEISMIC PEE
ELECTRIC FEE
PLUMBING ME
MECIIANICAL ME.
CONSTRUCUONTAX
PAID
Date
PA1V
1994
Uh71/
ISSIIP.O BY:
all