28205NPPLICANT TO FILL IN INFORMATION WITHIN RED LINES -
CI OF CUPENO
BU APPLICATION/PERMIT
BUtLDINC. DIVISION
LICENSED CONTRACTOR'S DECLARATION
1 hereby effrtn th n I am licensed anderprovidursol'Chapmr9 (commencing wish
Sectiona01of Division3 of she Business and Professions Cade, and my license is In
full force
antl effect.
License Class Lic.X
Date Contractor
ARCHITECTS DECLARATION
I understood my plans shall be used as public records.
Loened Pramssmnal
OWNER -BUILDER DECLARATION
I hereby affirm mat 1 an exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Profession Code: Any city or county
which requires a permit to construct, cher, improve, demolish, or repair any structure
Poor to its issuance, also requires the applicant forsuch permiuo rile a signed statement
mat he is licensed pursuant to the provisions of me Contmoora License Law (Chapter
9 (commencing with Section 7") of Division 3 of the Business and Professions Code)
or that he is exempt herefrom and the basis for the at leged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
❑ I. a ownerofthe property, ormy employees with wages ass theirsole compensation,
will dome work, and sbe stmcwre is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply an sit owner of
propeny who builds or improves thereon, and who does such work h i msel for through his
ownemployees, provided th d such improvementsare not inrtndimmoffered forsale. If.
however, the buildingor improvement is sold within one year of completion, The owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ has owner of the prolixity, am exclusively contracting with licensed caroms. to
consuuct theproject (Sec. 7W. Business it Profeaians Cade) The Commdors
License Law does not apply to an owner ofpropcny who builds or improves thereon.and
whomntmcts forsuch projects with accatracoms) licensed pursuanrto the Commuter's
License Low.
Cl I an exempt under Sec. . B & P C for this reason
W QXKMAN COMPENSATION DECLARATION
I hereby alErm Hurt have a cenificem of consbu m self -insure, ora ceni0case of
Workers' Compensation Insurance or aceniFied copy mereoFlSec. 3800, Lab C.7 which
aovers all employee's under this pertnis.
ahar #
Company
❑ Cenif al copy is hereby famished,
❑ Candied copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Ifshe permit is forest, hundred dollars ($100)
or less.)
I certify Thar in the performance of the work for which this permit is issued, f shall
nos employ any person in any manner so as to become subject to the Workers'
z Compensation Lawsof CWifomia. Data
v Applicant
NOTICE TO APPLICANT: If, after making Ibis Certificate of Exemption, you should
n become subject o she Workers Compensation provisions of the Latour Code. you muss
forthwith comply with such provisions or this Permit shall b<deemed revoked.
Q CONSTRUMON LENDING AGENCY
t z 1 hereby affirm that there is is construction lending agency for the Performance of
., the work for which this Permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender. Address
1 candy that I have read this application and state that the above information is
y cmi lagan rut comply with all city and county ordinances anJ stare laws relating to
,A building conswction, and hereby authorise representatives of this city to enter upon he
Z above-mentioned property for inspection purposes.
(We) agree m sone, indemnify and keep hamdess the City of Cupertino against
liabilities,judgment. es 9u agnd exp which may in any way acme against said City
conseyu-oe f e ra si r is eesml�
SignDolere of APp�icun4Canlmnol APOie•uv/4r.m/n:Iraorml
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sire or handle hazmd mos material
as helloed by the Cupertino Municipal Cade, Chapter 9.12, sad the Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
Will the appl icunt ar future building occupant use equipment or devices which emit
WJoos air munnumanls as defined by rhe Buy Area Air Quality Management
et?
❑ Y. ❑ No
1 have read the boredom mamrials requirements under Chapur 6.95 of the
California Health & Safely Code, Section 25505, 25533 and 2551. 1 understand that
if the building does not curently have a octant, mut it is on, res Wnsibilay to notify the
capent of the requirements which muss be met poor to issuance of a Cen im.th, of
Occupancy.
Owner authnnied agent Date
POINT PI
BUILDING
PLUMBING
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
Dun ET5-SWITCHES
-
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAMS- FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASEMIDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER HEATER WNENT/ELECTR
WATER SYSTEMnREATING
NEWRESIDE RAL PLMIL SQ. FT.
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
AIR HANDLING UNIT (TO 10." CFM)
AIR HANDLING UNIT (OVER 10,030 CFM)
EXHAUST HOOD(W/DUC)
I MATING UNIT (TO IOLM BTU)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP (HIP OR IBLISaft BIM
BOILER - COMP (OVER 100,000 BTU)
NEW RF.SIDF.NTJAL MECH. SQ. T.
r,FFIr.F
PERMIT NO.
28205
EN/C
ITARY NO. APPLICATION SUBMITTAL DATE
0: �a^� 5
CONTROL#
❑ ❑ p
Y
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Date Receipt#
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Date
ISSUED BY:
` e o
Cq y 221995
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