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CITY OF CUPENO APPLICATION/PERMIT
BUILDING DIVISION
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirmthat Iamlicerued mdapfovisionsofC aper9(commencingwish
Section 7000) of Di J of Ne Business and Profusions Code, and any license a in
full force end effect. 2 �
License Class /I 'Y'�'I_,Q_ be,medTSD TIO
unLic.#N/f
y/
Dam Con
ARCHITECTS DECLARAN
1 understand my Finns shall be uxd az public necanls.
Licensed Pausssimml
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt tram she Contactors License Law for the
following masonrw'm
ion]031.5, Business and Professi Any city car county
which ur,mm at to construct, alter, imp coolish, c air any swcture
prior to its issuanrequires thea such permittoElle igned smtcmcmthvt he is licenuuan cions of the ConeanorsLiven Law(Chapter
9(commencing01nn]0001 of DivisionJof the Business and dessionsCWe)
m that he is examrefrom wdthe basic for the alleged exemption. try violation of
Section ]OILShoppiicanttorn pernit subjects the applicant ton ivil penalty of
not more than fivdred dollars (1500).❑ Lasownermpeny, or my employee with wages as their sol ompensution,
will do the work,e swcture is not intended or offered Basics(Sec. 0414, Business
and Professions the Comrnvtors Lion a not apply an owner of
propenywhmbuipfPvesthere��((�stt and wh d uc himx orthroughhis
ownemployecs,edd isuchjlnpw notimm�dedoroff redformle. if,
builder will M1ave eburde V' not build prov�for Impose of
n of the grope y mexcl�bh',Ydxl
c acting vol licensed contmctors to
onswct the c mjee9 Bute Sessions
Code) The Contractors
Lieenu LawJ snot ean],I wn s w builds or immovnethereon. and
I afn efempt ma,'Ai'. wK—ILl , 0 -&SP G4., this reason
❑ I hereby affirm that l hale icenifcatenfconxnituxlf-inure, eracertifcamof
Wmkraf Compensation lruu o oeniftW copy thermf(S.. 3800. Lab C.) which
covers all employee's under this permit.
Policy N
Company
❑ Cenifedcopyiaheabyfumished.
❑ Cerl copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olds section need nmtbe completed if the permit is forms, hundred dollars (S 100)
less.)
I certify that in the performance of a work for which this permit is issued +]shall
not employ any person in an r eco to • rbje o AIC Workeri
Compensation Lawa of Cal' o
Applicant
NOTICE TO APPLI T: 1(afmp og this �Cer➢roa��m of
Hxemption, you should
become subject tothe Wnd ,".l perception provisions ofthe labor Code, you must
forthwith comply with such provlsime or this Femur shall be domed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 31197, Civ. CJ
1 certify that 1 have need his application and sum that me above informed. is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, end hereby numnze repancratives mthis city m cart, upon the
above-mentioned property for inspection purpoem.
We) agree to save, indemnifyand keep harmless she City of Cupertino against
IAZA OUS MATERIALS DISCLOSURE
Will theapp can furore building occupant time or hvMle haardous maenad
as defined by the Wino Municipal Code, Chapter 9.12, and the Health and Safety
Cash, Setion 25532(a)'t
❑ Yes ❑ No
Will the applicant or name building acupant use equipment or devices which emit
huzafdoos air conmminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hanudou, materials requirements under Chapter 6.95 of the
California Health & Safety Code. Sections 25505, 25533 and 25534. 1 under and that
if the building does not currently have a mount, fur it is my responsibility to notify the
occupant of the requirements which must be met poor to issuance of a Certificate of
Owner or authorized agent Data
ELECTRIC PERMIT
PERMIT ISSUANCE
XPPLIANCES- RESIDENTIAL
PANELS
UP TO 200 AMPS
201. IUW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR MILE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
)UTLETS- SWITCHES - FIXTURES X
NEW RESIDENTIAL ELF.CTR —SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURPS - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASEONDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER HEATER W/VENT/ELECTR
WATER SYSTEM(MEATING
NEW RESIDENTIAL PLMB. SQ. PI'.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,1X1) CFM)
AIR HANDLING UNIT (OVER 10,M CFM)
EXHAUST FOOD(W/DUCT)
HEATING UNIT (TO 1fiff" BTU)
HEATING UNIT (OVER IM." BTU)
VENTILATION FAN (SINGLE VENTILATION FAN (SINGLE RESID))
BOILER - COMP (3HP OR 100," BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH, SQ. FT.
PAID
Uae Rec
ISSUANCE
PAID
JUL
CIN
Or
ISSUED BY:
27892
SANITARY NO.
APPLICATION SUBMITTAI. DATE
I
NAC
X
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` V W
FEE
BUILDING CRMIT INFO
B� U MSCI
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IOB DFjG�
i
C1 r1l
SQ. FT. FLOOR AREA
S/SQ. FT.
7.52 SA
VAIUA]l0
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—
yn6AI 'YPECONSTRUCf10N
STORIES
OCC. GROUP
RES. UNITS
FLOOD ZONE
APN
FEE
as'•
FCC SUMMARY
OUT'SIDE MEN
SANITARY Y —N—
NRECEIPTat
RECEIPT at
SCHOOLTAX Y N
_.
RECHIPT M
PARK HE N
PTM
BWdQ#khIVAION FEES
PLANCHECKF �7
GRADIN
SOILS F .
ENERGY F'EE —�
PAID
Dat,
OTAL:
BUILDIN /�
svt FEE
FEE
PLU FEE
PAID
Uae Rec
ISSUANCE
PAID
JUL
CIN
Or
ISSUED BY: