26785APPLICANT TO FILL IN INFORMATION WITHIN RED LIP
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
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10 XaTCT:
L r�) PHONE:
Owe 2'83-21,00
LICENSED CONTRACT'OR'S DECLARATION
1herebyalEam that
lamlice.sedunderpmvisiomofC pter9(commenciagwith
Section 7")of Division 3 of the Business and Professions Code, and my license is in
full force said effect. — rJ 3/y�Clb/G
License Claa Liae f^
Data Contract
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any Overuse
prior to its issuance, also requires the applicant for such permit to file a signed statement
Nat he is licensed pursuant to the provisions of the C.ntmclors Licenx Law (Chap...
9 (commencing with Section 7") of Division 3 of the Business and Professions Cade)
or that he is exempt therefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1. as rwnerofthe property. or my employees with wages as theirsole compensation,
will do the work, and Nestrunure isnot intended or offered for sale (Sm.9044, Business
and Professions Cade: The Contractor's Lima. Law does not apply to an .wale, of
property who builds or improves thereon, andeshodeassuchwork himulfonhroughhis
wnemployme, provided thfl such improvementsmanot imendedoroffced formic, If,
h.weveq the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build in improve for purpose of
sale.).
❑ I, as owner of the progeny. sm exclusively contracting with licensed contractors to
construct the project (Sec. 9644, Business and Profusions Cale:) The Connector's
License Law does not apply be an ownernfproperty who builds or improves thercon,and
who contracts fmsuch projectswith a con ossam s)license! pursuant to the Contractors
Licenx Law.
❑ I am exempt under Sec. . B & P C for this reason
I Owrmr Date
W ORKMAN COMPHNSATION DECIARATION
I hereby affirm that l have a certificate ofroment to self -insure, or a cenifica..of
orlobs' Compensation Insurance or a certified copy Thereof (Sec. 38M, Lab C.) which
covers all employee's under this permit.
Policy 0
Company
❑ Canned copy is hereby fumishad.
❑ Certified Copy le filed WlN the city inspxlion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rot be completed if Ne permit is furore hundred dollms(SIM)
or less.)
I certify that In Ne pero matlee of the Work fmwhich this pernit Is Issued, I Shall
nm employ any person in any matlnce u as to become subject in the Works'
Z Compensalionlswsof Califomia. Date
Applicant
%p -r 0 NOTICE TO APPLICANT. If, afar making this Continence of Exemption, you should
�ill) become subject o the Worker's Compensation provisions of the Labor Code, you must
�' forthwith comply with such provisions or Nis permit shall be deemed revoked.
W Z CONSTRUCTION LENDING AGENCY
5 I hereby from Nat there is a aromatic. lending agency for Ne performance of
I,:p the work for which N 1, is p .it I. issued (Sec. 301Cir. C.)
Lends. Name
O ULenders Address
W I candy that 1 have read Nis application and Slam Thu the above information is
comma. I agree to comply with all city it county Dour. it ata.. laws catalog to
Dr, buikh",co acdrn.andlimebya .nae rep. ,m. es Ihia cirymrnmr upon the
L) z rhos'- coned pro try fm i qO/
r i rwi _ .n e me r Crrertir..a.maa
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building .,.,at stole or handle hsicrdous material
as defined by the Cupertino Municipal Cade, Chapter9.12, and the Health and S.fay
Cale. Section 25532(.)?
❑ Yes ❑ No
Will Nenpplicunt..furore building.cupum uueyuipmem mdav,cas whichemit
vud.m air contaminants ass defined by the Bay Arte Air Quality Management
istrict?
❑ Yes ❑ No
I have read the nmud.us materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
Vthe bolding does not commit, have a t..I, Kafir is my reapn..imiay m notify the
occupant of the om oiremenrs which must he mer prior to issuance of a Certificate of
Occupancy.
Owner or umhmized.gem Data
PLUMBING - MECHANICAL
ELECTRIC PERMIT FEE
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TD 20D AMPS
SPECIAL C CUE
TEMP. METER OF
POWER DEVICES
I\ :�OEIDSENTW,BCRS
"RES
R�LJ
.Fr.
26785
SANITARY NO. APPLICATION SUBMITTAL DATE
r2�
/C CONTROL.
BUILDING PERMIT INFO
34 KDiELECT' PLUMBO�GCH
•.JOB DESCRIP IIION , /176r
PD
V
SQ, FT. FLOOR AREA E/SQ. FT.
6)0-2�3 6-03
'S33y'13 D
PLUMBING PERMIT FEE FLGou ZONE — - -
PERMIT ISSUANCE
11
ALTER - DRAIN&VE T-WATER(EA) FEE SUMMARY
BACK FLOW PROTECT. DEVICE SIP -D DE FEIeS
SANITARY Y
DRAINS- FLOOR. ROOF, AREA. GOND. RECGIPI' _
SCHOOL TAX Y
FlXTURES-PER TRAP `� RECLI M_
PARK ME Y
GAS -LA. SYSTEM-] INC. OU RTS RECL'TN_
BUILDING DIV SIGN F
GAS - EA. VISTEM-OVER 4 (EA) PLANCHECK FEE
GREASETRAP �l I
SEWER-SANRrPRY-STORMEA.700F1'.
WATERH� TER W"W,1'I.ECTR
WATERS MEATMG
NEW RESIDENTIAL PLMB. SQ. Pr.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST FOOD(W(DUCI')
HEATING UNIT (TO IM." BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE. RESID)
BOILER - COMP (3HP OR 109,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECIL SQ. FT.
FEE
ENER i,Y ME %w_
e
PAID
Rec<iptg
TOTAL:
BUIL
N F. if
SEISMIC FEE
ELECTRIC MIi
PLUMBING M
_
PAID
Duro
6`410
Jut OU
ci/yv� 9g�
;SUED BY: