25977)LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PY OF CUPERTINO ' iRiy-EI MIT
BUILDING DIVISION APPLICATION/PERMIT PJ:-MECIIANI
- BUILDING
NC PPROROJECT NNN'1'1
U''&Ar y Tin -J-0811
I.ICFNSBD CO CfORsAsON
1 hereby of ism Net I un licensed under provisions of Chapser 9 (commencing with
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full force and effect.
License Class Lie. at
Date Contractor
ARCHITECTS DECLARATION
1 undershtnd my plans shell be tall as public records.
Co°¢ OWNER -BUILDER DECLARATION
p6F 1 hereby affirm that 1 am exempt from the Connector's License Lew for Ne
3- following reaven. (Section 7031.5, Business end Professions Code: Any city memory
EL 0y � which requires a permit to c ... inner, after, improve, demolish, or repair say svucore
trt^aIIY� Interior its issuance. Wsorequires the applicant(orsuch permilm file. signed Sediment
Kipm Cat be is licensed Formal 10 Ne provisions ofthe Contractors License Law(Chepnr
eLL 9(commencing with Section 7000)of Division 3 ofthe Business end Professions Cade)
_oo or that he is exempt therefrom good Ne basis for Ne alleged rampart Any violation of
tZaY Section 7031.5 by any applicant for a permit subjects the applicant o a civil praly of
an more Nun five hundred dollars (8500).
❑ I, as owner ofthe properry. no my employees wit wagesax theirsole compensation,
a wil l do the work, and the structure is not intended or offered forsale(Sec. 7M4. Business
end Professions Cade: The Conmcar's License law does not apply to an owner of
properly, who buildsorimprovesthcmunend who does such work him alter Borough his
own employees, provided that such improvements ufe not intended or offend for sale. If,
bow co have
Megorimpmproviniahat he
iiinoneyeu or improaion purpose
of
builder will have the burden of proving that he tliJ not build or improve far purpose of
salt.).
❑ I,es rafth (See, 70,14,
Business
ss a contmcPonfiesaimis C ste:) n Contractors
Licnseconsumer the project (Sec. o Business and ywhob ll CWeO The Centers d
License Law does such
applyton ownerofpropertywhobutIda s bacproves Contortend
who re Lacer forsuchprojcets with acantracorte)licensed Pascal to Contractor's
License Law.
❑ 1 oro exempt under Sec. , B & PC for this mason
Owner Data
WORKMAN COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of cream to selginsure, or a eenificare of
orken' Compensation Insurance cracertified copy thereof(Sec. 3800, lab CJ which
Percy a
Campany
❑ Co ifiedeopyishenbyfumiahed.
❑ Cenffied copy is filed with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section or«d not be completed i f the permit is for one hundred dollen ($100)
car lase.)
1 certify her in the perf. of Ne work for which Nis pends is issued, l shall
not employ any person in any manner so u in become subject to the Workers'
ZCompensation Laws of California, Date
Applicant
Z 0 NOTICE TO APPLICANT: If, afar making this CmtRcate of Exemption, you should
r+Vi lecomc subject to Ne Worker's Comperes ion provisions of she labor Cade, you must
L� forthwith comply with such provisions or this pemsit she[] be dcemM revoked.
> CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a construction lending agency for the perfmmunce of
O the work for which this permit is issued (Sec. 3097, Civ. C.)
L8. LeMer's Name
OLender's Address
UI1 certify shat I have read this applicetir end are Cat the shave information is
correct. l space to comply with all city and county mdinences and scale laws refining to
I"' N building construction, and hereby authanze representatives of this city to enter upon the
Uz above-mentioned property for inspection putpma.
(We) agree to save, indemnify, and keep harmless the City of Captain. against
liabilities. judgments, costs and expenses which may in anyway accrue against said City
in consequence nce of the gaiting of this permit.
HAZARDOUS MATERIALS DISCLOSURE
Will Ce applicant or future building occupant sore or handle haaardaus material
as defined by the Cupertino Municipal Code, Chapter 9,12, end she Health end Safety
Code. Section 25532(a)7
❑ Yea XNo
Will the applicant or future building occupant use equipment or devices which emit
havudous air conrnirnts as defined by the Bay Area Air Quality Marginal
strict?
❑ Yes )(No
I have need the hazallous materials requirements under Chapter 6.95 of the
California Hedth & Safety Cade, Sections 25505.25533 rd 25534. 1 endernrd that
if the building docs not currently h ea tonent, It Iia my respansibility to notify the
occupant of the rcgoimorrcn mjyg pro o issuwre of a Certificate of
Occupancy. /.— ot c.. nw
*S-%?_ 090 o
a LATA
.� ELECTRIC PER
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
POWER
V OIf11.ETS -SWITCHES-Fl%TURFS [/ l
NEWRESIDENTIAL ELECIR _SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN&
BACK FLOW PROT�ICL 9EVIR
DRAINS - FLOOR, F, A, s�s^ . U
FIXTURES- JERTRAIDATE /
GAS - BA. SY iENTB-INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASE MAP
SEWER - SANITARY. STORM EA. 20017.
WATER HEATER W/VENT/ELECTR
WATER SYSTENIMEATING
NEW RESIDENTIAL FLUID. SQ. ff.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,00(1 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,001 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
FEE
FEE
09pa
FEE SUMMARY
Y
PAID
BUILDING FEE
SEISMIC FEE
PAID
P-4
' o
0j��p�.j� 19R4
ISSUED
25977
SANITARY NO.
APPLICATIONSUBMUNALDATE
NIC
❑
CONTROLa
1. I Lto-a
FEE
BUILDING PERMIT INFO
BLDG PLUMB MFCH
❑
/
IOB DESCRIPTION
POWER
V OIf11.ETS -SWITCHES-Fl%TURFS [/ l
NEWRESIDENTIAL ELECIR _SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN&
BACK FLOW PROT�ICL 9EVIR
DRAINS - FLOOR, F, A, s�s^ . U
FIXTURES- JERTRAIDATE /
GAS - BA. SY iENTB-INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
GREASE MAP
SEWER - SANITARY. STORM EA. 20017.
WATER HEATER W/VENT/ELECTR
WATER SYSTENIMEATING
NEW RESIDENTIAL FLUID. SQ. ff.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,00(1 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,001 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
FEE
FEE
09pa
FEE SUMMARY
Y
PAID
BUILDING FEE
SEISMIC FEE
PAID
P-4
' o
0j��p�.j� 19R4
ISSUED