27687—T
APPLICANT TO FILL IN It
CITY OF CUPERTINO
BUILDING DIVISION
WITHIN RED
APPLICATION/PERMIT
22303 Q� 1 `vkZG C\rCAC- Nof'*A;;
full l
Live
Dao
c( 04 �3�•6frt8-
LICENSED CONTRACTOR'S DECLARATION
'(firm Nal l amlic,n e4 underprovisionsaf atipter9 (commencing wilt
of Division 3 right Business and Professions Code, and my literati is it
I understand my plans shall ba used as
OWNER.BUILDER DECLARATION— — ' -'--
1 hereby affirm that I am exempt from the Contractors Licerue law for she
following reason. (Section 7031.5. Business and Professions Code: My city or county
which requires a permit to construct, alter, improve. demolish, or repair any structure
prior 0 its issuance, also require the applicant formula pewiuo file taigmal statement
that he is licensed pursuant to me provisions of the Contractors License Law (Chapter
9 (commencing with Section 700y) of Division 3 of me Business and Profession Code)
or that he is exempt therefrom and the basis for me alleged exemption. Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant to u civil Purely of
nm mom man five hundred dollen ($500).
[3I. asownrmthe property, ormy employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Cede: The Contrachns License law does not apply to an owner of
property who buildsorimproves thereogand whodoessucM1 wodhimulfmthrough his
wermmployees,prosmed thauuchimprovementsme notimeadedmighani Porsale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner oftheproperty, am exclusively convecting with licensed conuactarxto
construct the preject (Sec. 70ol Business and Professions Cade:) The Contreuors
Li anti Luw does not appl y to en owner of property w ho buil ds m improve. thereon, and
who axama sfm...h projects withacambecrm(s) licensed pursuan mate Contrimmea
Litems, Law.
❑ 1 atir exempt under Sec. , B & P C fm this maxon
Owner Data
WORKMAN COMPENSATION DECLARATION
�-
WmkcIrMv' ConumnrsmnimonaInsurance conout/ nthuercof(Secns.u3
re8
,0o0r, Lm C.) which
Policy#_L1- — 'sem 0-1
Company
❑ Crnified copy is hereby furnished.
Canifim copy is filed with me eity inspection di '
CERTIITCATEO EXEMPTION FROM WORKERS'
COMPE ATIONINSURANCE
(nisacctionneednosbecomp uriiflhcpennitisfmonehundroddollan(5100)
m leas.) n
Iccrfifythuinme grammes me work for which On 'ssmad'Imall
not employ any person in any men r e m bewma e e Workers
Compensation laws of Califamia. D e
O Z Applicant
Z O NOTICE TO APPLICANT: ILmfur ani to`eo� pati y u ould
r t/) become subject m the Workers Compe an rovi'mus, (e Lts C must
, forthwith comply with such provisiore rt wit shill Wrivoked.
0.Q CONSTRUCfn LENDING AGENCY
Z 1 hereby affirm mat thea is a con tion lending agency fm me omunce of
U O the work for which this pemds is use (Sec. 3097, Civ. C.)
Lenders Name
O IaWer's Address
I certify that I have read this appl anon and a that the abode information is
�'s W connect I agree to con ply with Jl city an coun rdinancesandxtamlawsrelatingto
Iy' buildingconswction, and hereby autharim MWnMives ofthis city menur upon the
U z above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap brimless the City of Cupertino against
limilities,judgmenm, cons and expenses which may in any way .cera agi ins, said City
in or,,Mumwa of the granting of this permit. _
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or future building occupant store or handle haardom materiel
u defined by he C.,mi o Municipal Cc le, Chapter 9.12, and the Health and Safety
Code. Section 255 32(a)7
❑ Yes ❑ No
Will the applicant or future building acupant use equipment or devices which emit
haraslous aigronmminms as defined by the Bay Area Air Quality Management
Dimict7
❑ Yes ❑ No
I have read the hauudons materials requirements under Clmpur 6.95 of the
Cdifomia Hemrh & Safety Code, Sectimn.25505, 25533 end 25534. 1 understand that
if the talking does not currently have a tunam, that is is my reaponsi aili.. to notify the
mcupam of the requirements which most be at prior to issuance of a Certificate of
Occupancy.
agent
SE BALL POINT PEN ONLY
—BUTMING7 LECTRICAL
PLUMBING - MECHANICAL
FLOOD ZONE
PERMIT NO.
'/ 8
C 8J
BUILDING PROJECT' IDENTIFICATION
LOTS
SANITARY
NO.
APPLICATIONSUBMHTALDATE,
/�L`
I l 2
,AC' 'S NAME: LIC
I\A G>f G.�
NO:
/0
NIC
N/C
O D'F''iE3
CONTROLN
SS:
;kSSYg EEE@I'RI PERMIT?Tf,,
BUILDING PERMIT INFO
BLDG
ELECT PLUMB MECH
PERMIT ISSU° E
APP14AN(;?F-RESIDENTIAL
ON
^ yes
g1L�/� Aev.1g fel!® _
PANELS
UP T0200 AMPS
SIGNS ELECTRICAL
SPECIALCIRCUMMISC.
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEWRESIDENTIALELECTR _SQ.FT.
PLUMBING PERMIT .
PERMIT ISSUANCE 2
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA. COND.
RPS - PER TRAP
GAS \.SYSTEM
-1 INC. 4 OUTLETS
GAS - F .SYSTEM -OVER 4(EA)
GREASdRNDUSTRL WASTE INTERCEPTOR
SANITARY - STORM EA. 200"L
HEATER W/VENT/ELECIR
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)
EXHAUSTHOOD(W/DUC )
HEATING UNIT (TO 100,000 BTU)
HEATING MIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RMID)
BOILFR - COMP GHP OR 100,000 BTU)
BOILER - COMP (OVER 104)," BTU)
NEW RESIDENTIAL MECH. S(
FEE
FLOOD ZONE
FEE SUMMARY
O D'F''iE3
SANITARY
Y h
RECEIPI'p_
SCHOOLTAX
Y h
RF.CF.11'f M
PARK HE
Y h
RECEIPT a_
BUILDING DIVISION J
PLANCHECK FEE
GRADING FEE
SOILS PEE
ENERGY FEE
PAID
Date
Receipt#
FEE
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCfIONTAX
PAID
Dau
r—