26321APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPENO APPLICATIONIPERMIT PLUMPERMIT NO.
BING. MECHANICAL 26321
BUILDING DIVISION BUILDING PRTI
TURCT IDENTIFICAON
Ig:WCIB1
LICENSED CONTRACTOR'S DECLARATION
py.Z I hereby affirm that lam licensed anderprovisionsof Chapmr9(commeaeiag with
F100 Section 7000) of Division 3 of the Business and Professions Code, and my license is in
Fri Up full force and effect.
G'ZZ� License Class Lit.#
tiQd Dam Cono-acter
ZOyK ARCHITECT'S DECLARATION
O Z 6 D 1 anderstsad my plans shall be used as public records.
OZ
F;
q.] Licensed Pmfessi0nel
KCwu OWNER -BUILDER DECLARATION
XaU 1 hereby affirm that 1 am exempt from the Contractor's License Lew for the
¢130.vFi following mason.(Section 7031.5, Business and Professions Cade: Any city or county
"J �; which requires aem
ptit to construct, alter, improve, demolish, caran
repair y sounure
�WQn prior to its issuance, also requires the applicant for such permit to file a signed stamment
µl (y-1004 de)0 that he is licensed pursuant to the provisions of the Contractors License Lew (Chapter
d ,9(commencing with Section 700E of Division 3 of the Business end Professions Co
W—m
or that he is exempnherefrom and the basis for the alleged exemption. Any violation of
[-.Za Section 7031.5 by any applicant for a permit subjects the applicant m e civil penalty of
^�
ni mora than Bvend
hured dollars ($500).
mC m ❑ I, as ownerofthe property, army employees with wages as theirsole compensation.
y will do the work, and the domain, is not intended or offered for sale (Sec. 7044, Business
and Professions Cole The Contractors License Law does not apply an an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. 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 now net of the property, am exclusively contracting with licensed contractors to
rnnstmel the project (Sec. 7004. Business and Professions Code) The Contractor's
License Law does not appl y m am owner of property who builds or Improves thereon, and
who contracts foramb projects with acontmemr(s) licensed pursuant to the Contractors
License Law.
C]I am exempt under Sec. , B & P C for this reason
Owner Data
j WORKMAN COMPENSATION DECLARATION,
r] I hereby affirm that l have a cerifiwte of consent to self -insure, oro certificate of
'Ala isCompensation Insurammor a certified copy thereof(Sec 3500, Lab C.) which
cover, all employee's ander this permit.
PMicy #
Company
❑ Certified copy is hereby famished.
❑ Certified copy is filed with Ne city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectionneed notbe completed ifthe permit is foronehundoxidollurs(5100)
artless)
1 certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers
Compensation Lawaof Cnlifomie. Data
Z+ Applicant
,2 0 NOTICE TO APPLICANT: If, after making this Certificate of Exemption, ymu should
H [A become subject o the Workars Compensation provisions of Ne Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
Lki CONSTRUCTION LENDING AGENCY
Q I hereby affirm Nat there is a construction lending agency for the performance of
0 the work for which this permit is issued (Sec. 3097, Civ. C.)
Lka Lender's Name -
O Lender's Address
�" LU1 certify that 1 have read this application and state that the above information is
comet. I agree to comply with all city and county ordinances and most laws relating to
Dol building construction, and hereby authorize representatives of this city to enter upon the
C-3 y above-mentioned property for inspection purposes.
m� (We) agree to save, indemnify and keep harmless %a City of Cupertino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
in consequence of the grn aing of this permit.
Signature o'Applicam/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hama and Safety
Code, Section 25532(a)7
❑ Yas ❑ No
Will theapplicanmr fulurebuildingoccupant useequipment ordevices whichemit
havtrdoos air contaminants as defined by the Bay Area Air Quality Management
Aisrbit?
❑ Yes ❑ No
1 have read the hica mns nwmtial, requirements under Chapter 6.95 of the
California Health & Safety Code, ScuthoSivM05,25533 and 25534. I understand that
if the building does notyyirt tly hon,tieterloIdi, that i Is my responsibility in notify the
Deco ant of the r te m w a met rnyymuae � ifi K f
1 9
Owner or thonzed she^� Had
(]a.4ADn.-
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
201- 1000 AMPS
SIGNS ELECTRICAL t`
SPECIAL CIRCUIT/MISC.'
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEWRESIDENTIALELECIR _SQ.Ff.
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER (EA)
BACK FLOW PROTECf. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - G. SYSTPM-I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASF/INDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 20(1
WATER HEATER W/VENT/ELEC7fR
WATER SYSTEM/IREATING
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE -
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (1'O BLOW CFM)
AIR HANDLING UNIT (OVER 10," CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER, COMP LIPP OR IOg0110 BTU)
BOILER - COMP (OVER UIL" BTU)
NEW RESIDENTIAL MECH, SQ. FT.
' US
FEE
FEE
FEE
BUILDING PERMIT I
BLDG ELECT PLUMB
❑ ❑ Ig
JOB DESCRIPTION
Dr? 1N �
SQ. PT. FLOOR If AD A
ED ON
U TE
FEE
SCHWL'1 AN Y N
RECEIPT q
PARK FEE Y N
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Dam Receipt#
TOTAL:
BUILDING FEE
SEISMIC FEE
ELEC IHC FEE
PLUMBING FEE
MECHANICAL. FEE
CONSTRUCTIONTAX
PAID
Date
MECH
El
Ip p,%D
". 281994
�r roo
11Y'
ISSUED BY: