26565FY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby afr,mthat I am licensed underprovisions ofChapter 9(commencing with
Section 7") M Division 3 of the Business and Professions Cale, and my license is in
full fou and dfret. yrs . I
License Class D Lie. p.�T1 2_46
OLS I understand my pions shall be used as public records.
F nE;
a i�4
Licensed Professiunol
C� <
F OWNER -BUILDER DECLARATION
aJ 3 L I hereby affirm that 1 and exempt fiom the Contractors License Law for the
fallowing rstem,(Seelinn 7031.5, Business and Prehensions Cade: Any coy. Tenant,
which requires a permit to construct,alter, improve, demolish, or repair any suvetum
KMM 7 prior to its ismancaalso requires clientalicnm(ranch permitm file. ai,.m statement
v)K�pz dot he is licensed pursuant the provisions ofthe Contractors License Law (Chapter
LyeLL 9(commencing with Section7") of Division 3 ofthe Business and Professions Cale)
W% or that lie is exempt therefrom and the basis for the alleged exemption. Any violation of
7y< Section 7031.5 by any applicant for u permit subjects the applicant to a civil penally of
Out more than five hundred dollars 155 W).
W ❑ 1, asownerof the property, or my employees with wages as theirsole compensation,
will do the work, and the structure is not intended or offered forsale(Sec. 7044, Business
and Professions Calc The Contractors License Law does not apply to an owner of
property who builds ter improves thereon, and who duns such work himself or through his
n employees, provided that such improvements am not intended or offered for sale. If,
however. the building or improvement is sold within one year ofcomplenion,the owner -
builder will have the burden surprising that he did not build or improve for purpose of
sale.).
❑ I, its owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Corrector's
License law does not apply to an owner of proper y who builds in improves thereon, and
whocontmets for such projects with a contr.etoths) licensed pursuant to the Convectors
License Taw.
❑ 1 an exempt under Sea , B & P C for this reason
Owner Date
�cov WORKMAN COMPfiNSAT10NDECLARATION
,$ers'Co suffer that nlasudr acor certificate copyil nowt See. re,or Lab C,) which
of
keno' Compeyee'a code,
thnce permit. caddied copy thereof (Sw.3gIXl, Lab CJ whleM1
rx all employee's under Nis permit.
Policy p
Company
❑ Cenified copy is hereby famished.
❑ Certified copy is Bled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This talion need not becomplard ifthe permit is for one hundreddollan (SIM)
orless.)
1 certify that in the performance of the work for which this Permit is issued, I shall
not employ any person in any msrmer to as to become subject to the Workers
z Compensation Laws of Califomis. Date
Applicant
z 2 NOTICE TO APPLICANT: If, after making tots Cenificme of Exemption, you should
L� V] bwnme subject to the Worker's Compensation provisions of the Labor Code, you must
Lam; forthwith comply with such provisions or this From, shall he dimmed revoked.
aQ CONSTRUCTION LENDING AGENCY
Vz 1 hereby affirm that there is a construction lending agency for the performance of
O the work for which this pool[ is issued (Sec. 3097, Civ. C.)
Lk.r.t Lenders Name
0 U Lender's Address
I certify that I have read this application and state that the above information is
acomet, 11. to comply with all city and county outlanders and nuts lows relating to
buildi ng construction, and hereby authorize representatives ofthis city to enter upon the
U above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabibriea,judgments, ants and expenses which may in any way memo agvnst said City
to consnymna of the ¢amine of this rental. /
Data
Will the applicant or future building occupant store or handle hazardous material
as relined by the Cold inn Municipal Code, Chapter 9.12, end the Ileahh and Sulety
Cade, Section 25532(o)7
❑ Yes ❑ No
Wit l the applicant or future building occupant use equipment or devices which emit
haznrdnus it commensals as defined by the Buy Area Air Quulily Managemenr
Dnarl
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the
Calibloul- I health & Sulety Code, Section, 25505, 25533 and 25534. 1 understand that
if the building does nm currently have a m urn, that it is my responsibility to notify the
Occupunt of the requirements which must be met prior to issuance of a Certificate of
cupancy.
Owner nr authorized agent Date
POINT PEN ONLY
—HUILD7Ni: = R1:FTTRTL
PLUMBING - MECHANI
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
d", a EES,
1 �
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEWRESIDFNTTALELECIR _SQ.FT.
' $ t'$ 'PLUMBING PERMIT,
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (FA)
BACK FLOW PROTECf. . ICE
DRAWS - FLOOR F. AREA. COND.
FIXTURES :R TRAP
GAS .SYST'IIM-1 INC. 4 OUTLETS
AS - EA. SYSTEM -OVER 4 (EA)
CRN.ASFJINDUSTRL WASTfi INT tRCEI'fC
OREASF. TRAP
SE WEft - SANITAPA - S*PW. 200F1.
TOTAL:
ME9161CAL PERMIT
ACI'ER OR ADD TO MF.CIL ' 1
AIR HANDLING UNIT (TO 10,800 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD ( W/DUCD
HEATING UNIT (TO I00,000 RTU)
I [BATING UNIT (OVER 100,000 BTU)
VENT'ILAT'ION FAN (SINGLE REBID)
BOILER - COMP (311P OR 100,M0 BTU)
BOILER - CAMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECIL SQ, FT.
FEE
BUILDING FEB
SEISMIC FEE
ELECTRIC FEE
PLUMBING ITE
MECHANICAL ITE
CONSTRUCTION TAX
PAID
Date
PAID
JUL 2 01g�
Vti..gffw
0 �
26565
SANITARY NO.
APPLICATION SUBMITTAL DATE
6 --It"
N/C
CON 'I'ROLa
-
FEE SUMMARY
Bl1ILDING PERMIT INFO
BLDG ELLLEECCT
PLUMB MECH
e1
❑ ❑
OR
�y `
I
�iQD�
RECHIPT # _
SQ, PI'. FLOOR AREA
FT.
1
{^/ /♦_S/SQ.
8 1t7;l
VALUATION
Ili _s/L
1•TIfv '
FEE
BUILDING FEB
SEISMIC FEE
ELECTRIC FEE
PLUMBING ITE
MECHANICAL ITE
CONSTRUCTION TAX
PAID
Date
PAID
JUL 2 01g�
Vti..gffw
0 �
FLOODZONE
;'FHHyn =
-
FEE SUMMARY
O TSI 1':ES
SANITARY
Y b
RECHIPT # _
SCHOOLTAX
Y
RF.CHIPT#_
PARK FEE
Y h
RFCRIPT#
BUILDING DIVIS ON FE
PIANCHECK 19Ai
GRADING FEET
SOILS FEE
'
ENERGY FEE
PAID
Date
Receipt#
TOTAL:
FEE
BUILDING FEB
SEISMIC FEE
ELECTRIC FEE
PLUMBING ITE
MECHANICAL ITE
CONSTRUCTION TAX
PAID
Date
PAID
JUL 2 01g�
Vti..gffw
0 �