24685RED
OF CUPENO
BU APPLICATION/PERMIT
BUILDING C DIVISIOSIO N
0 3Sq a
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions -(Chapter 9(commencing with
Section 7000) of Division 3 of the Basin'. and Professions Code, and my license is in
full form and efiat.
License Clara Lim.I
Data Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
sawn OWNER -BUILDER DECLARATION
�gOaF I hereby ernam ractors
That I exempt from the ContLicense Law for the
Wig: LLOmfollowing rcnson Saturn 703 L5, Business and Professions Ode: Any city or county
y n which requires a permit to c-marowl, aIle', improve, demolish, or repair any emsetom
K2¢2 Prionohsisuams, als mquimstheapplicantf-'such N.inofileasignesstolement
W R5p 0 that he is licensed pursuanu0 the provisions of the Contractors License Law (Chapter
f o"1 9(Commencing with Section]DDD) of Division 3 of We Business end Pmfcssio.Cads)
wMon or that he is exempt demfmm and the basis for the alleges exemption. Any violation of
QSection 7031,5 by any up,licum far B permit subjects the uppluaid ron civil penalty fall
t mare than rive hundred dollars (S3f10).
it. ❑ do theLasowtr,andt eshouy,ormycmtendedawi offered
orsale Sec. compcnsiness
m 3 -. sell
d pe -go work, and e: Timam eai con'. Out Laded Lgov e, rum apply to
-Baines
and Professions Cole: The,,,scars License law does not apply to Bra owner of
merenywhobuildsorimpmvesch improandwotor, etchwork.,Offredthmughhis
hOwem the
ebuiprovided imat provement
isg gold
within not intendedmoeemd(oasts. r-
however, the building Of improvement is sola within one year of completion, the owner -
builder will have the burden of proving that he did nm build or improve for purpose -f
tight.).
constan the protect (Sec. 7(N4, Business and Professions Code) The Contractor's
Llan Bu Law ems not apply m w -wan of prnpertY w ha nu i l ds w improv es thereon, and
who customer for such Prujeeu with a commuctons) licensed pursuant to the Conrmetnr4
License law.
❑ 1 am exempt under Sm. , B & P C for Nis reason
ysvner Date
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that 1 have a ceAficole ofc-1 m self-insum, or a cerrifirem of
brhen' Compensation Insurance or a certified copy thereof(Sec. 3800. Led, C.) which
aver, all empl-yea's under this permit.
Pull, M
Comp y-
❑ Certified copy if hereby famished.
❑ Certified copy is fticd with the city inspection division.
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars (5100)
or less.)
I terrify thin in the pert( -'mance of the work for which this Permit is issued,) shell
not employ any pc,wo in any manner so as to become subject to the Workers
zCompc.mimi Laws -f Califomn, Dole
Q O Applicata
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
F^ fn became subject to the Wnaeers Compensation pe vision of the Labor Coda you must
jforthwith comply with such pmvisiom or his .it shall be deemed revoked.
A CONSTRUCTION LENDING AGENCY
z I hereby affimt that there is a construction lending agency for the performance of
J O the work for which this patent is issued (Sec. 3097, Civ. C.)
Loader's Name
Isnder's Address
ti 1 certify that 1 have read this application and sate that the above information is
correct. I agree to comply with all city and county ordinances and stage laws minting to
building construction, and hereby aummim representatives of this city to enter upon the
Z above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liubildies,judgments, Owls and expenses which may in tiny way accrue against said City
in consequenci of the granting of this permit. ,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or (mum building occupant srom-r handle h membaus material
I s def ned by the Cupeainu Municipal Code. Chapter 9.12, and the Health and Safety
Cade, Seetion 25532(e)P
❑ Yes VN.
Will me applicant m future building occupant use quipnrmordeviceswNchemit
aiardom air contaminants ofdefined]by the Bay Arta Air Quality Management
Istrinl
❑ Year No
1if0�11adifaC'C,upmgcY. I have mad the humate
rdous retiuh requirements under Changer 6.95 of the
can Hea1N&SafeyCode,Sectio.25505,25533and 25534. 1underataMtmthe building does notet rently have a moral, that his my responsibility to notify the
PERMIT ISSUANCE
APPLIANCES -RESI
ELECTRICAL
s ❑
FEE BUIL
BLDG I
\Ill
DD,
4 SO. FT. Fl,O(it
§PUTLE1'tt- SWITCHES -FIXTURES ` agagage
NEWRESIDf:N'EALELECIR _SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM.] INC.4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (PA)
GREASEdNDUSTRL WASTE. INTERCEPTOR
GREASETRAP
SEWER - SANI'T'ARY - STORM EA, 2WFT.
WATER HEATER W/VF,NT/ELECTR
WATER SYSI AMEATING
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO Ig00D CFMI
AIR HANDLING UNIT (OVER Ia,Wo CBM)
EXHAUST HOOD(W/DUCI)
HEATING UNIT (TO 100." BTU)
I BEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER COMP OHP OR IOLD)0 BTU)
BOILER , COMP (OVER I00.0110 BTU)
NEW RESIDENTIAL MECH. SQ. PT.
OFFICE
FEE
BUILDING FEL'
SEISMIC HE O
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dam
JAN 20 7993
CIIY Ur l,urrnlugo
"TrJ w ��
3
STORIES
TYPE CONSMI.
,CTG P
ES.
D
FLOOD ONE
An
E IB
FEE SUMMARY
UT DE
SANITARY
Y__ry__
RECEIPI'st
SCHOOLTAX
YN__
RECEIPT.
PARK FEE
Y N__
RECEIPp
BUILDING DIVISION FEES
PLANCHECK FEE
' GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Dole
Receipt g
TOTAL:
BUILDING FEL'
SEISMIC HE O
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dam
JAN 20 7993
CIIY Ur l,urrnlugo
"TrJ w ��