27389CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
PHONE:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am Ii enxd underprovisions ofC apta9 (commencing with
Section 9OVB of Division 3 re the Business and Professions Core, and any license is in
lull force and effi e,
License Claw I.ia#
Ilam Contractor
ARCHITECT'S DECLARATION
I understand my plans shut l Is, used as public rer.rds.
licensed Professional
OWNER.RU11.DER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city m county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its 19-srac, also requires the applicmn for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 900) of Division 3 of the Business and Professions Code)
m that he is exempnhcmf can and the basis for Me alleged exemption. Any violation of
Section 9031.5 by any applicant for a pemtit subjects the applicant n a civil penalty of
not more than five hundred dollars ($500).
❑ I, as ownerof the property..r my employees with wages its their sale compensation,
will do the work, and the structure isnot intended oruff acd for Sale (Sce.7O44, Business
and Professions Code: 'I he Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who doss such work himeclf or thmugh his
hoemployca,pmvidnithat sucM1 improvements areae' imm�dedoroffcrW forsale. If,
wever, the building or improvement is sold within one year ofcompletion, theowner-
builder will have the burden of provingthat he did not huild or improve for purpose of
mlc.).
❑ I,asowneroftheproptiny,amexelusivclycontraaingwiNlicensedconwctorsto
Lnetrua The project (Sac. 9044, Business and professions Code ) nic Contractor's
icense Law does not apply man owner ofproperty who builds or improves Ocreom,and
who contracts for such projects with a contranorfid licensed pursuant m the Conoanor's
License Law.
❑ l am exempt ender Sec. . B & P C for this reason
Allill WORKMAN Cf1MPE14SATION DECLARATION
❑ Iherehy affimT'huTlhavc acenifiwm nl ronsenno ulf-ineure..raceniliwte of
Worked Insurance or ittnified copy thereat(Seco 3800,Iab CJ which
- covers all employes,'s under this #coni'.
Plicy N
company
❑ Certified copy is hereby furnished.
❑ Cenificd copy is fled with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the pem'it is for one hundred dollars ($100
n less.)
1 certify ohm tribe performance of the work for which this permit is issued, I shall
not employ any person in any manneras to became subject to the Workers
z Compenamicn Lawsof Culifomia. Dam
so
Applicant
z C) NOTICE TO APPLICANT:If,ofter making this Certificate of Exemption, you should
Fy become subjmno'he Worker's Compensation provisions of the lsMr Code, you mon
> forthwith comply with such provisions err this permit shall be deemed revoked.
C CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a construction rending agency for the perfoamadee of
U O the work for which this permit is issued(Set. 3097, Civ. C.)
Lenders Name
U.
E" Leadds Address
V I really that 1 have read this application and stem that But above infonnmion is
FgL correct. I agree to comply with all city and county ordinances and, state laws relining'.
.. fn building construction, and hereby au'horim representatives of this city m enter upon the
U z abtwcmentloned property for inspection purposes.
(We) c m save, if
end keep hwmless the City of C.Pcnino against
'labii".,IuJg a,consyadexpure,24lT,ch may in anyway accrue against said City
ma",
eel Nis u� f
HAZARDOUS MATERIALS DISCLOSURE
Will ffi—pplicam or future bnilding occapint sore or handle laica ous in"amel
as defined by the Cupcnine Municipal Code, Chapter 9.12, and the Ilealth and Safety
Cuda, Section 25532(a)1
❑ Ycs ❑ No
Will the applicant or future building occupant use equipment or devices which emit
harardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
1 have read the haendous materials requirements under Chapter 695 of the
Calil.mia Hi Ith & Safety Code, Sc alum 25505, 25533 and 25534. 1 i nde.sc nd that
if the building does nm cuncntly have a term, that it is my responsibility as notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Dae
POINT
a -
PEN ONLY
'NMI] DIN(77EITM' Ed
PLUMBING - MP.CIIANI
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTUNUSC.
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEC R _SQ. FP.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VIM - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS -FLUOR, ROO REA. COND
FIXTURES PER TRAP
1
GAS - EA. SYSTEM -I IN .
GAS - EA. SY3TEM VE 91fEA)
GREASETRAP
SEWER - SANITA
WATER
WATER SYST'
NEW RESIDENTIAL
27389
FEE I BUILDING PERMIT INFO
B1LEG ELECT PLUMB MECH
W ❑ ❑ ❑
_f
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER Oft ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10.010 CFM)
EXI IAUS'T I IOOD (W/DUCT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100.010 B -I U)
VENTILATION FAN (SINGLE RESIDE
BOILER - COMP (3HP OR I0(L" BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. PT.
TOTAL:
FEE
Z -_X- . Aoy G//-;"4
A Y
AAWufC
FEESUMMARY
BUILDING ITC
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEF.
MSCI IAN'ICAI. FEE
CONSIRUCTIONTAX
Y N
RECEIPT#
Y N
Receipt#
PAID 1 S
Date Receipt#
I'OTAI
ISSUANCE DATE
FEB 15 1995
CII Y Vf V�Vf!rark I I14U
ISSUED Bi"s \1JCC J
a
4901 �_
OCC. GRf
TOTAL:
FEE
FLOOD Zt
SANITARY
SCHOOLTAX
PARK FEE
BU
PLANCHECK FEE
TOR
GRADING Flit?
SOILS FEE
f.
FEE
FEE
PAID
Dme
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER Oft ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10.010 CFM)
EXI IAUS'T I IOOD (W/DUCT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100.010 B -I U)
VENTILATION FAN (SINGLE RESIDE
BOILER - COMP (3HP OR I0(L" BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. PT.
TOTAL:
FEE
Z -_X- . Aoy G//-;"4
A Y
AAWufC
FEESUMMARY
BUILDING ITC
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEF.
MSCI IAN'ICAI. FEE
CONSIRUCTIONTAX
Y N
RECEIPT#
Y N
Receipt#
PAID 1 S
Date Receipt#
I'OTAI
ISSUANCE DATE
FEB 15 1995
CII Y Vf V�Vf!rark I I14U
ISSUED Bi"s \1JCC J
a