26207;ANT TO FILL IN INFORMATION WITHIN RED LIP
CUPERTINO
I S APPLICATIONIPERMIT
LICENSED CONTRACTOR'S DECLARATION
I hcrehy affirm that I an I icenand under provisions of Chapmr 9 (commencing with
Section 7") M Division 3 of the Business rM of save d dmy licanx is in
full targe and a i(�,i. m_
'Class �L Lic. p
Dem Contractor
ARCHITECTS DECLARATION
I understand my plans shall Its used v public records.
Licemed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I sat exempt from the Contractors Liceme Lew for she
following reason. (Section 7031.5, Business and Profusions Code: Any city or county
which inquires s permit in emiswm, alar, improve, demolish, or repair any awctuta
Prior to its issuance, also rtquires me applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the ContractorsLicense Low (Chapter
9 (commencing with Section ]000) of Division 3 of the Husiness and Professions Code)
Us- that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant w s civil penalty of
not more than five hundred dollars ($500).
❑ do
wrk,andreStrucy,ormyemployeuwithwed fmsalei(Sol. (ppl,Bssdoa,
veil do the work, and the he Con is tat intendedor
ave do for sale (Sol. 4044. Business
and Professions Code: The improves
umean. License Law tiers not apply lf an owner of
property who
yebuilds orimmovsu thereon,andwbo doenouchwde hirofffour through his
own howeer,tyeasilding rimponvchimprovpmensSol ne fear of c oroffered forthe oe. wner-
bowevrwthe building improvement is sold within one of completion, me. ase Of
builder will have me burden of proving mat he did not build or improve for purpose of
sale.).
❑ L as owner of the propeay, sat exclusively contracting with licensed loomecome to
com ucr the project (Sec. 7044, Business and Professions Code) Thr Conowun s
License Law does not apply man owner mproperry who builds or improves thereon. and
who contracts for such projewts with a conwctor(s) licensed pursuant to me convectors
License Lew.
❑ 1 am <sempt under Sac. , B & P C for this reason
n WORKMAN COMPENSATION DECLARATION
I hereby affirm that 1 haves ceniftcme.fconsent to self-insum, me vertificare of
en Compensation Insurance ora certified copy thereof (Sec. 3800, lab C.) which
S all employee's under this permit.
❑ Cenifa l copy is hereby famished.
❑ Cenified copy is filed with the city inspection division.
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be ex mplerad if thepermit is forms hundred dollars ($100)
tar loss.)
1 Om ify mat in me perfomunce of the work for which this permit is issued, l shell
.or employ any person in any rammer so as to become subject to the Workers'
Compemi
nsonlawsof Califlundo Data
-
C) Applicant
7 NOTICE TO APPLICANT: If, after malting this Certificate of Faemptim. YOU should
become subject to me Workers Compensodmt provisions of the labour Code, you must
a +
forthwith comply with such provisions or this permit shall be domed revoked.
Da G CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a comoractan lending agency for the perforri of
O he work for which this permit is issued (Sec. 3097, Civ. C.)
U. ��++ Lenders Name
0 t' Lenders Add..
WI artily that I have mad this application and sate that the above information Is
correct. Iagmemcomply withal] city erW county oMinanas encimrel. a.l.d.gto
building convection, and hereby auth.rim epresenubves ofthis city to enter upon the
(� z above-memionel proprny for inspection purposes.
(W t0 save, inti sty and kap hannl a City of Capetian against
Iiabiliriesqu f,h cos Bexpergcswhich may'm way eccrvesg;^inat-ACi�
in co99�rt (rhe tin of Permit. N
PLUMBING -MECHANICAL
PERMIT ISSUANCE
APPLIANCES .RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECIHUCAL
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE MST,
POWER DEVICES
SWIMMING POOL ELECIN IC
FCUTLETS-SWITCHES-FIXTURES
NEW RESIDENTIAL ELECM _SQ. FT.
FEE BUILDING
T
V 26207
' TIONSUBMrrrALDAT7E
CONTROL#
.MIT INFO
'LUMB MECH
❑ ❑
MON
I S/SO. Ff.
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
--APN
ELECTRIC FEE
QTYg p MECHANICAL PERMIT FEE.
PLUMBING EEE
PERMIT ISSUANCE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ALTER - DRAIN & VENT- WATER (
AIR 14ANDLING UNIT (TO IO,IXq CFM)
FEE SUMMARY
AIR HANDLING UNIT (OVER IO.M CIM)
OUI'SIDP
BACK FLOW PROTECT. DEVICE"A�ejSANITARY
HEATING UNIT (TO 100,1100 BTU)
YN_
HEATING UNIT (OVER IOO.WO BTU)
- L: Ia
RECEIPT#
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOLTAX
Y N
BOILER - COMP (3HP OR10,MBTU)
PAIp
RECEIPT#
FIXTURES - PER TRAP
ARK FEE
Y N
CITY Ur
RECEIP #
GAS - LA. SYSTEM -I INCA OUTLETS
BUILDING DIVISION
GAS - EA. SYSTEM -OVER 4IRA)
PLANCHECK FEE
GREASEANDUSTRLWASTEINTERCEPTORDING
ME
GREASETRAP
S SME
SEWER -SANITARY -STORM EA. 200FT.
AGY FEE
WATER HEATER WIVENT/ELECTR
PAID,
WATER SYSTEM/I'RPATING
Dat
RaC tp
NEW RFSIDFNTIALPLMB. SQ.FT.
TOTAL:
WBPfhe applicant or future building oo( pant store orhandle haaordom material
US defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.)?
Cl Yes ❑ No
Wilitheeppliantorfutuebuildingoecupamusee uipmentordeviceswhichemit
heurdous air c.saminams ns defined by the Bay Area Air Quality Management
gistrict?
9 ❑ Yes ❑ No
T 1 have read she hamrdous materials requircmens under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if me Wilding does nm cumendy have. snam, slim it is my asponsibiliry to notify me
cupant of the requirements which all be met prim to issuance of a Certificate of
Occupancy.
Owner Or mdmn cd.gens Data
TOTAL: I TISSUED BY: V I 1 j
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTYg p MECHANICAL PERMIT FEE.
PLUMBING EEE
MECHANICAL FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
CONSTRUCTION TAV
AIR 14ANDLING UNIT (TO IO,IXq CFM)
AIR HANDLING UNIT (OVER IO.M CIM)
EXHAUST FOOD(W/DUCT)
PAID
HEATING UNIT (TO 100,1100 BTU)
Data Receipt #
HEATING UNIT (OVER IOO.WO BTU)
- L: Ia
VENTILATION FAN (SINGLE RPSID)
'
ISSUANC DATE
BOILER - COMP (3HP OR10,MBTU)
PAIp
BOILER - COMP (OVER I(IO,00) BTU)
NEW RESIDENTIAL MECH. SQ. FT.
.rygpyee((
NAR29 1994
CITY Ur
Wrizhurva a —
TOTAL: I TISSUED BY: V I 1 j