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26122OKZ WOO ecU FZw os a zo= OZ4f..0 Nt�at a C.J za�a �OdV w3ay F+Oa 2 W < oLLLL FZa - EFG a o O0 z.. ti a>_ a0 z UO �U ri Uz %PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING - N BUILDING DIVISION PP 41 �/ysn/� ��/;y¢ys},!py'NPi{BUILDWC P/ROJEECT 3UIjNG ADD LICENSED CONTRACTOR'S DECLARATION 1 hereby affud Nat I am licensed underprovisions ofaripmr9(commencingwim Section 7") of Division J of the Business and professions Code, and my license is in full force and effect. License Class Lic. e Dom C- ---ARCHITECTS DECLARATION I understand my plum shall the used a public moords. Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I wn exempt from the Convenors License Low for the following reams (Section 7031.5, Business end Professions Code: Any city or county which outlives a permit to consumer, alar, improve, demolish. or repair any svuctute Puerto to issuance, also outlines the applicant for such permiuo file a signed segment Net he is licensed pursuant to the provisions of the Conmemrd License law (Chapter 9 (commencing with Section ]000) of Division J of me Business and Professions Code) or that he is exempt therefrom and the breis for the alleged exemption. Any violation of Section ]031] by any applicant for a permit subjects the applicant o a civil penalty of not mom than five hundred dollen ($500). ❑ I.mownerofthepropeny,mmycmploymwitbwagons irwlecompensadan, will dothe tv h.and thesvuctureis not incendcdaoffesedforWe(Sc.]064. Business and Profession, Code: The Casa mtoh Li. law doe at apply to an owe of property whobunIdsmimproves fl eeon, endwhodaosuchworkhimselforthrough his own employes. Provided tom such improvements ase not intended reoffered (aside. If. however, the building or improvement is mid within one yesrofeampletion, therwner- builder will have the burden of proving that he did not build or improve for p b"m of sale.). ❑ Las consucr the nproject (Sec Business malProvfuusiouo Coaliet) The Countesses License lawdmnot apply oanownerof propend who buildsrp npmve theourand whfor projecwith acrfa) licensees purposes to she Contractors eence Low. ts mvcw ❑ I am exempt under Sec. . B & P C for urea ream Owner Dem WORKMAN COMPENSATION DECLARATION �,❑ Ihwcby affirm thal Mveacmificme ofansruto elf -insure, orecati.)w c enw I Wreri al Compemedre Immuno or aanified copy therm((Sc. Jg00, tab C.) which m all emPloYee'r under dda pcmvn Policy M Company ❑ CenifiW copy is hercbY fumishM. ❑ Certified copy is filed with the airy inspcuon division. CERTIFICATE OF EXEMPI70N FROM WORKERS' COMPENSATION INSURANCE (Thu section intestinal be completed i f Ne pe phit u fortune h undroddollars (SIM) or I..) 1 certify duo N the perfomum, of the work for which his Permit is issued, l shall not employ any peon in any m ander eco a to become subject in the Wohen' Compensation Iowa of Califomia. Dao Applicros NOTICE TO APPLICANT: If, after malting this Cert f. to of Exemption. you should becomesubjecttome Workefs Com dmprovisimuofthe Labecode,ymmust forthwith comply with such provisions or this pemdt shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hceby affirm that Nee is a conduction lending agecy for the perfomuna of the work fa which this permit is issued (Sec. 709], Civ. C.) 1 cetify Wt 1 have mad this application and state that Na above information is cored. I agree to comply with ell city and county ordin.Pm and dote laws elating in building commitment, and hereby euthalm tepteenotive of mu city w rotes open the above-mendmsel property fa insisted. operates. (We) agree to save, indemnify and keep hermlm Jou City of Cupertino against liabilities, judgments. costs and eapenses which may in my way seems against said City can}ec,s c..f the ,ening of thi ,,Vrin. HAZARDOUS MATERIALS DISCLOSURE Will the applicant car (orae building occupant dart or handle harerdom material an defined by the Cupertino Municipal Cole. Chapter 9.13, and the Health and Safety Code, Section 35573(.)1 ❑ You ❑ No Willtheupplicanmrfmumbuildingmcupuntume uipmentordeviceawhichcmit ha mons air contaminants as defmW by the Bay Area Air Quality Management District! ❑ Yo ❑ No 1 have read the Institutions mamdNs rcquiemenu under Chapter 6.95 of Ne California Health R Safety Code, Sections 8505.35533 and 25534. 1 understand Nat tithes building does nor curcndy have o wort, mm it is my responsibility to notify me acupant of the requirements which must be met prior m issuance of a Certificates of Occupancy. PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANELS UP TO 2W AMPS .. SIGNS EI SPECIAL TEMP. M POWER v. J NEW BAIDEVTIAL ELECTR _SQ. FT. I - 26122 iANITARYNO. APPLICATIONSUBMITTALDAI NIC CONTROL # —Q x-3-'3%4SUILDWG PERMIT5NFO;rii�,rub��w'-"`'. BLDQ E,SLIEEC�/T PLUMB MMEECCCH JOB DESCRIPTION REA IO'-`. K R A 130 %0 4— OCC. GROUP PERMIT ISSUANCE ALTER-DRAW@VENT- WATER(EAJ ��r�'�sfly8$IJ(rQ�SARY -- BACK FLOW PROTECT. DEVICE SANITARY Y N RE�IPT g DRAW F. S - FLOOR. BOOK AREA. COND. SCHOOL TAX Y N RECEIPI'g FIXTURES - PER TRAP �� PARK FEB YN RECE x GAS -EA. SYSTEAl INC. 4 OUTLETS D SIGN GAS - EA. SYSTEM -OVER 4 (EA) PLANC GREASEJNDUSTRI, WASTE INTERCEPTOR G cREASETRAP SOILS FEE r SEWER- SANITARY - STORM E.A. 2WFT. ENERGY FEE aaaaaa WATER NEATER W/VEN'DELECTR PAIDDate WATER SYSTEM/IREATING con . NEW RESIDENTLV. PLMB. SQ, FT. TOTAL: PERMIT ISSUANCE �s ALTERORADDTOMECH. AIR HANDLING UNTT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10A00 CFM) EXHAUST HOOD(W/DUC) HEATING UNIT(TO 100,000 BTU) HEATW G UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) astassal BOILER - COMP (3HP OR 100,000 BTt11 BOILER - COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH.—SQ. FT. BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTIONTAX PAID Date APR 15 1994 CITY OF CUPEj- p ISSUED BY: Z5r�tl IN