27691e
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CITY OFCUPERTINO I """"""`
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MRCIfANICAL27691
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LICENSED CONTRACTOR'S DECLARATION
Im
cont Iso.R&7-i7/
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ADDREB 6/ (O L
EI:ECI'RIC PERI
PERMIT ISSUANCE
with APPLIANCES -RESIDENTIAL
is in PANELS
UP TO 200 AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 sm exempt from Ne Contractor's License Law for the
following reason. (Nation 7031.5. Business and Professions Code: Any city or county
which requires a permit In construe, .her, improve, demolish, or repair any strpemre
prior to its issuance, also requires the applicant far such pamem to file. signed statement
Mat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commeming with Section ]1100) of Division 3 of the Business and Professions Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for. permit subjects the applicant m a civil penalty of
no, me than five hundred doll. (S500).
❑ Las and
openy,ormyempineorofwegesmthei(Se Business will du the coons and the he Conure e tot intendedse Law
do s hot apply
t oan owner
of
and Professions Cada The Connector's License Lew does not apply lf an owner of
propertywhobuilroodmpmvesthrreogandwnodoessuch wodhimxened I. am.his
own employ buiprovidr ithatsve improvemenisarenot ear ofr moffered forsaln, the n IL
however,thebvethe or improvement of proving ethediold inone tbuildorimproeforurposer-
bale.). will have the burden of proving that he did not build or improve for purpose of
ole.).
❑ 1, as Me pr ject (Sec. 701,1,
exclusively coo.feingwlthrm:) etl contractors
comes. ow project (Sec. oano Business and ywho build CWeB The Central, and
License
tractones such
apply toanowterotmaop sywho dIdsmimprovesthereon,end
who contracts for such projems with ecmmnctnr(s) licartud pursu.nnothe Contractor's
Littme Law.
❑ 1 am exempt under Soc. , B & P C for this reason
Owner Dam
WORKMAN COMPENSATION DECLARATION
❑ I nereby affirm that l have a cenifiesue ofconsent to self -insure, or a certificate of
�Wmkera CompensWon Insurance or v certified copy thereof (Sec. 3800, Lab C.) which
cove. WI employee's under this permit.
Policy?
Company
❑ Cenifhed copy is hereby fomishW.
❑ CertiRed coPY is ftW with the city inspatiun division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if Ne permit is for one hundred dollen I$100)
or less.)
I jrirythatinthyyeKarmen o�rwor ar .. .,nW.I snWl
am Noy any pvfYfi m an me subiat to Ne rn
F.Applicant
z NOI'ICF. T PPLICANT: IL e8 r making this Certiftca a of Exemption, you should
become subject to Ne Workers Comprnaation Provisions of Ne Labor Code, you must
forthwith comply with such provisions or this pemtt shall be deemed revoked.
aCONSTRUCTION LENDING AGENCY
'a z 1 hereby affirm that them is a construction lending agency for the of
U O the work for which this permit is issued (See. 309'7, Civ. C.)
FI. lender's Name
O lender's Address
kTI1 certify that I have mad this application and state Net the above information is
6. correct. l agree to comply with all city and county ordinances and state laws relating to
VJ building concoction, arW hereby authorise representatives of this city to enter upon the
U7
G above-mentioned property for inspection pursuers.
(We) vane m save, inderalL491nd keep harmless the City of Cupertino agMost
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardc m material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and Ne Hralth and Safety
Cede, Section 25532(X?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which emit
baurdous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
1 have rend the hevudons materials requirements under Chapter 6.95 of the
California Health & Safety Cade, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tensnL that it is my responsibility to notify the
occupant of the requirements which must h met prior to issuance of a Certificate of
Occupancy.
Owner or toulun and agent Data
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC,
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEWRPSIDENTALELECIR _SQ.FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR, ROOF, AREA, CON
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS_
GAS - EA. SYSTEM -OVER 4 (EA)
GREASRIINDUSfRL WASTE INTERCEPTOR
GREASRTR,P
SEWER - SANITARY - STORM FA. 200FT.
WATER HGTER WIVENTIELECfR
WAMR SYSTEM(IREATING
NEWRESIDENTIALPLMIL SQ.FT.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER Ill." CPM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 108.008 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 100,000BTU)
NEW RESIDENTIAL MECH. SQ. FT.
ST
FEE
BUILDING PERMIT INFO
BLDG ECT PLUMB MEC'.
❑ ❑ ❑
1 ^JOB DESCRIPTION
FEE
FLOOD ZONE.
APN
FEE SUMMARY
6UT—§rDCTM
SANITARY
Y —N—
N_RECEIPT#
RECEIPT #
SCIIOOLTAX
YN_
RECEIPT M
PARKFEF.
YN_
RECEIPT#
BUILDING DIVISION FEES
a
PLANCHECK FEE
GRADING FEE
SOILS FEE
ERGY FEE
r
Dam
Re«opt M
TOTAL:
FEE
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
I" A 1 eJ
Af 0if 8.9
cir1994
ISSUED BY: