30108APPLICANTTO FILL IN INFORMATION WITHIN
CITY OF CUPERTINO
BUILDING DIVISION 'u �PMLIC,ATf
EG 6uKamQ 540-Z2
I hcrehy .Minn char I am licensed under provisions of Ch!
th Section 7000) of Division 3 oflhe Business and Professions Cr
full force and effect.
:ame Class Lic.M
toContractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
LINES - USE BALL POINT
J. Ma O'1�}EI �•L
DDRfiS ,.
❑ Consultant Fees Paid by Applicant (Initial)
,TY. ELECTRIC PERMIT FEE
OWNER -BUILDER DECLARATION
1 hcrehy affirm that
I am enanpt from the
the Commctor's ny License Law fanhe
following reason, (Section 7031.5, 13mmiss and Professions Colo Acity or coumy
which cabanas a permit to eonstmet, alien improve, demolish, or repair any somemrc
prior to its issuance, also requires the applicant for such Perming File a signed statement
that he is licensed paramon In the pmvniom of the Camou,u is License Law (Chapter 9�
(aro mnatng with Seelma AKK) of Division 3 of the B.'inus and Pndessimw Cale) or
thus he is exempt therefrom and he basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil Penalty of
not mora than five hundred dollars ($5110).
❑ 1, as owner of the property, for my employees with wages as their sole compensation.
will do the work, and thestntmnre is or landed or offered for sale (Sec. 7614, Business
and Professions Cala The Con #gam's License taw does not apply to an owner'of
property who builds or improves thereon, stat who does such work himself or through
his own employees, provided that such improvement, are not intended or offered for
sale. If, however, the building or inipmvement is sold within one year of completion, the
et -builder will have the burden of proving than he did not build or improve for .pur-
rose
❑ 1, as owner of the properly, am exclusively,commeling with licensed commcros to
Construct the project (Sec. 7W4, Business and Processors CakU'The Contractor's Li-
cense law does not apply man owner of fragar y who builds or improves themen. and QTY,
who emnr m.. for such pmju is with a contractors) licenced pursuant o the Commemrs
License haw.
iminammptunder Sea ,B& P C for this reason
(Owner Date
WORKER'S COMPENSATION DECLARATION,
1 hereby eff3rm under Penalty of perjury one of the following declarations:
(] I have and will eraimuin aCenificme ofConsem m ulf-insure for Worker's Compen-
smion, as Provided for by Section 37(k of the labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Compensation lnsumnca, as required by Section
37M of the Labor Cade, for me performance Oldie work for which this permit is issued.
My Workers Cnmprnsatlom Imuruns, carie, and Policy mmi are:
Cartier: 9Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed Fil e f main is become hundreddollas ($100)
or less.)
Lamifythasintheperformanceofthe work forwhich mis pcnnit is issued,Ishall
not employ any person in any manner so m In Beeman subject to the WorkersCun,wn-
O Z no. Laws of Caldron.. Data
y Applicant
q u NOTICE TO APPLICANT.If, after making this Cenilicate of Exemption, you should
become subject mine Worker, Compensation provisions of the labor Code, you must
forthwith comply with such provisions or mis permit shall be deemed revoked.
(]y Q CONST RUCTION LENDING AGENCY
U (hereby affirm thin mere is a conswnion lending agency for she performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
0 V lenders Num.
Leaders Address
p, 1 cenify that 1 have read this up,1i,u i,m and stain that the abase information is
ti y cort l agree to comply with all city and county ordinances and state laws relatingto QTY.
V 4 building commcrion, and hercbyaallamis represenlalives fthis citym eaerupon the
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino amain,,
l iabilides,judgmens, costs and expenses which may loamy way acerae against snid Croy
in consequence of the gaming of this permit.
APPIJCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
-------Rf'1RE6US MATERIALS DISCLOSURE
Will thenppheant or fmurc building nccupme sere mhvndiehvort Li
it, defined by the Canard.. Municipal Code, Chapter 9.12, and the IIcahn and Safety
Code, Sarin. 25532007
❑Yes ❑No
Will the applicant or fume, building occupant use equipment or devices which
emit hvardous air contaminants ns defined by the Bay Arco AirQuality Management
D'shicf: ,
❑Yes No
1 have mail the transactions mmenals rcquiremens under Crisper 6195 of the Cali.
forma Health & Safety Code, Sections 25505, 25533 and 25534. 1 undeamnd at dire
building distinct currently have a ¢nam, mal it is my respondhilily on artily the occupant
of the requirements which must he met friar to issuance of a Certificate of Oce.,uns,
APPLIANCES — RESIDENTIAL
PANELS
UPTO 200AMPS
SIGNS ELECTRICAL
SPEY (Cull'/MISC.
i'.M RPOLE INST'
PO IEVIC .
sL EL IC
OUTLBESIDE
ES—FIXTURIS
NIiW AL SQ IT.
ALTER — DRAIN&VENT — WATER .A)
BACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF, AREA, COND.
FIXTURES—PERTRAP
GAS —E OMIDQMGVUT' 'EAi
GAS— FA. SYSTFMa3VHR 4(FA)
WATER
WATER
NEW R'.
ALTER OR ADD TO MF.CH
AIR HANDLING UNIT 0`111
AIR HANDLING UNIT (OVE
EXHAUST GOOD OMMUCT
HEATING UNIT (TO 1011.000
s VENTILATION PAN FdN .. ID) 7
BOILER — COMP (3HP OR I0B000 BT
BOILER — COMP (OVER 1011((00 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ:IT.
E
JOB DESCRIPTION \
30108
NITARY NO.
APPLICATION SUBMITTAL DATE
❑PLUMBING RE -PIPE
El MULTI -UNIT
V ice, 1.
NIC
CONTROL#
11 INTERIOR
El CHIMNEY REPAIR
BUILDING PERMIT INFO
L'LF PLUMB MECH
pleat\
JOB DESCRIPTION \
RESIDENTIAL
CSFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
El MULTI -UNIT
[]STRUCTURAL
' MODIFICATION
11 INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
COMMERCIAL' '
❑NEW BLDG/ADDITION ❑DEMOLITION
ANT ❑ FOOD SERVICE
ROVEMENT
❑0 ER Z A
SQ. FT. FLOOR AREA $/SQSQ. FLOOR AREA $/SQ. FI'.
4
CirJ�N 21; 996
FEE
Receipt p
TOTAL:
FEE
PLUMBING FEE
MECHANICAL FFE
CONSTRUCTION TAX
HOUSING MITIGATION FE
TOTAL:( (ISSUED BY:
OFFICE
Done