27007ILICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
rY OF CUPERTINO xa,Illxiso�
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT DIEM IFICA
LICENSED CONTRACTOR'S DECLARATION
Ry�Ihumbyaffit Ite11smliunscdunderpmvisioruofChapter9(commencingwith
00Z Section 9a W) of Division 3 of the Business and Professioru Code, and my license is in
'UE full force and effect.
p<ZWLicense Clan Lic.It
oo-" Data Contractor
Z 0rNisZ ARCHITECTS DECLARATION
OZ ❑ ?undersand my dars,hill be used as public mcorda.
arq SyIII
�dd'j Licensed Professional
Sys Q OWNER -BUILDER DECLARATION
°a 0 Is. U I hereby affirm that I em exempt from the Connecmr'a License Law for she
following roman. (Section 7031.5, Bminns and Professions Code: Any city or county
uJ ON ¢ which requires a from, to construct, after, improve, demolish, or repair any structure
uu^]]YJ� prior to its issuance also requires the applicant for such Permit to file a signed statement
�Cyqp @a he is licensed paramour to the provisions of the Contractors License Law (Chapter
X� 9(commencing with Section 9000) of Division 3 of the Business and Prolamines Code)
DEF-I�y or that he is excmpnhcreftum and the basis for the alleged exemption. Any violation of
Z4Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not moa then five hundred dollars (5500).
m p ❑ 1, as, ownerofthe property, many employees with wages as their sole compensation.
p, will dorhe work, andflemormuseianm inumd,simoffered fnade(Ser.7D44, Business
and Professions Cade: The Contractor's License Law does not apply to m owner of
own emy who buildsorimprovsuch improvements
mpr and whoduer such work himselfedf roughhi,
employees provided that ouchim is sold itherenm intended ofooroffend for aide. 1L
however. the building orden ofpmensisholdwithinoneyea ofcompletion,theowner-
aide). r will have Me burden of proving that he did not build or improve fm puryom of
ale).
❑ Las ma the pr of jest (See ny,em Business
andly Professions
withcontractorsCocm
mnawat the project (Sec, aanoneof and Professions CodeThe Comracmnd
License Law does not apply cl m owner of property who se itch m improves Communities
omm, end
who cmwets fm such Orojecss wi N n contractor(s) erred pursuant so the Cmux mIh
License Lew.
— -❑. I am exempt under Sec. , B & P C for this mason
Owner
Dat
WORKMAN COMPENSATION DECLARATION
s covers�❑l hereby affirm that i have a certmm
ifiofconxnsto self-insure.oracatifiwtn of
Worke9 Compensation Insurance or acmi0ed copy fiertof (Sec. Jtl00, Lab CJ which
ell employcc'a under thio permit.
Policy
g
Company
❑ Candied copy is hereby fum ecity
❑ CenirMthe city
ed copy is ed with inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Gatinction read not hecompleted ifthe Permit is fmonehundredd.11.(5100)
or less.)
I ceNfy that in the petfomunm of the work for which this permit is issued, I shall
not employ any person in any mamer so as to become subject an the Worker'
Compensation laws of Celifmnia. Data
0 z Applicant
z 0 NOTICE TO APPLICANT: If, after making this Cenificste or Exemption, you should
r+IAj become subject to the Worker's Cmnpewdm provisions of the labor Code, you must
farrhwish comply with such provisions rostra pemdt shall be downed revoked.
CONSTRUCTION LENDING AGENCY
��- z I hereby affimr Out there is a construction lending agency fm the performance of
O the work for which this permit is issued IS.. 3097, Civ. C.)
f� Lander'a Name
0 l^ Lender's Address
W 1 crnify that I have rad this application and sum that the above information is
Imre,. legit mcomply wi0r dldry and manly ordinenceaend eurelews reletingm
F-' � building constroction, and hereby audomin representatives of this city m enter upon the
Vabove-mentioned property far inspection p
(We) .'ream save, indemnify sand p leu the City of Cupertino .1mal
liabilities, iudgmrrks.cmawdexlsen whit A any way acerae against said City
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hvardous material
at defined by the Cupertino Municipal Code, Chapter 9. 12, and he Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
Will Ne aPplu msmfunne buildingoccupwtuseequipm<ntordeviceawhicherttit
harsNous air comamirana as carried by he Bay Are. Air Quality Management
District?
Cl Yes ❑ No
I have read the hmurdot. marerid, requirements under Chupmr 6.95 of the
Culifomia I leulth& SaferyCade, Sectiom 25505, 25533 and 25534. 1 undermd Net
if she building does not currently have a tenant, that it is my responsibility to notify the
occupant of the reguiremenss which muss he met prim to issuance of a Certificate of
Occupar'.
UNIT# LOT
V 6. DeAnit
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS EI
SPECIAL
TEMP. M
_SQ.
y TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE.
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASFJINDUSTRL WASTE INTERCEPTOR
GRHASETRAP
RY - STORM EA. 200Ff.
WIVENT/T:LECTR
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(WIDUC)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,0(s0 BTU)
VENTILATION FAN (SINGLE RISID)
BOILER - COMP GHP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH, SQ. FT.
27007
SANITARY NO. I APPLICA O/NNSSUB HTALDATE
NO: v
N/C O ROL
r ❑
PEE BUILDING PERMIT INFO
ELECTMECH
ElM ❑
JOB DEWRIPTION
FEE
FEE
FEE SUMMARY
PLANCHECK FEE
GRADING ME
SOILS FEE
ENERGY FEE
PAID
Dam Receipt #
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEF.
MECHANICAL IEE
CONSTRUCTION TAX
PAID
Dam
'�' �, e
gEP 16 199