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26871APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPERTINOU W LULCa: - LLLt, t Rta:AI, PERMIT NO. APPLICATION/PERMIT PLUMBING - MECHANICAL ItUIhDING DIVISION BUILDING PROJEM'ID NTIRCATION 26871 [full.]) �ADURI: SANITARY NO. APPLICATIO1NS�UBMMALDATE V A,V LOT# C� • J OWNS PHONE: ONTR 'S N h E: LIC NO: N/C ❑ CONTROL. # rRCHITF.C1'/ENGINEER: LICNO: ADDRESS: CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO LICENSED CONTRACTOR'S DECLARATION Oder Iherebyaf can that l am licensed under provisions of Chapter 9(__.ad., with ¢100 Smnim7000)oi Dlvlslon3ofthe Buslnessond Professions Cod e, end my limnaisin z V F full force and effect. <VIn License Class Lie. of vias Date Contractor 7~Oy- ARCHITECTS DECLARATION O Z _ ❑ I un lcom nd my plans dill be used as public records. P,4 L: j Licensed Professional �y.Ca OWNER -BUILDER DECLARATION �'OyU I hereby affirm that I am exempt from the Convectors License Law for the 3LL,Fn following reason. (Section 9031.5. Business and Professions Code: Any city or county which rcyuircs a permit to cousWq, utter, improve, demolish, or repair any structure ,W}7 prion... issuance, also requires theapplicant for such pertniuo file. sigreedstammem 5 G p that he is liccoscd pursuant m the provisions of the Comuectors License Law (Chapter d Kai 9(commencing with Section 7") ofDivision 3offee Businessand Professions Cade) m—m or that he is exempt herefrom and the hasis for the alleged exemption. Any violation of FZ,Q Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of �-E not more than five hundred dollars ($500), ❑ lasowncrofthepropmny,ormyemployxswithwagesm1heirsolecompensation, a3=° will do the work, and the structure is not intended proffered Bosse (Sm.]tW4, Business and Professions Coda The Commmur's License Law does not apply to an owner of property whobuildsor improves thmenuo nd whodoessuchwork himulforthsough his own employees, provided that such impmvementsare not intended or offered forsale. If, however, the building or improvement is sold within one yearofcompletion, the owner. builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I, as owner ufthc property, ran xclusively contracting with licensed contractorsm construct the project (Sec. TWO, Business and Professions Code:) The Contractors License Law does not apply IOU mwnerofprorany who builds or improves thereon, and who contracu forsuch projects with acenuactor(s) licensed pursuant to the Contractors License Law. ❑ 1 am exempt under Sec. , B & P C for this return Owner Date WORKMAN COMPENSATION DECLARATION Workers orkersCompensation o eeionaInsurance orsicami naed copy Llab C.) which rsallemploycssutlnthispermt. f Policy X Company ❑ Canned copy is hereby famished. ❑ Certified copy is filed with the city inspersion division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This action need not be completed ifthe Permit is fiction, hundred dollars ($lop) or less.) 1 canary that in the performance of the work for which this permit is issued.) shall not employ any person in any manner so as to become subject to the Workers' z Compenestionlawsof California. Date Applicant z NOTICE TO APPLICANT:If. after making this Certificate of Exemption, you should (•-' > a > forthwith comply wthieth Wsuch Provisions oor this Permit shall tithe Labor Code, you mon be decreed revoked. Gw. O CONSTRUCTION LENDING AGENCY z 1 hereby affirm that there is t construction lending agency for the performance of V O tae work for which this permit is issued (Sec. 3097, Civ. C.) `sn ka'a Nuns O U Landers Address 1 cenify that 1 have read this application and sore that the above information is F bar construction, and with alleiry end representatives of and stat slawsr upon the U. Z huildi-menti ructtomert horinsputhrriu rpseentaGvea of this city treater upon the U z ebov(We).9. property for inspection purposes. (We) ogres orsave, indemnify and keep harmless the CityCupcnss em is, expenses w ch may in any way accrue against said sai:d City to caneWee ofthe grant: Alhis'Pl.a 6� HAZARDOUS MA'I17RIAM DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the C,amro Munici WI Code, Chapter 9. 12, and the Health and Safety Cade, Section 25532(d? ❑ Yea ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management D'ulrictt ❑ Yes ❑ No 1 have mad the horrendous mmerials nalmo meats under Chapter 6.95 of the Califamia Hedth & Safety Code S«tions 25505, 25533 and 25534. 1 understand that if the building does not curarly have a tenant, that it is my responsibility to notify the occupant mile, requirements which must de met prior to issuance of a Cenifieme of Owner ar authnnved .,at Date PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 2W AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTR SQ, FT, BLDG ELECT PLUMB JOB DESCRIPTION Foe% zF,J PLUMBING PERMIT FEE FLoo PERMIT ISSUANCE ALTER - DRAIN & VENT - WATER (EA) BACK FLOW PROLE .DEV` \ SANITARY DRAINS - FLOOR OOF. AREA. CON_.. SCHOOLTAX FIXTURES PER TRAP PARK FEE GAS .SYSTEM -1 INC. 4 OL)`SETS _x - EA. SEWER- 97A ;A. FT. WATER 11 EN WATER SYSTEM EAT[ NEW RESIDENTIAL B. SQ. FT MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT ITO IBOOp CPM) AIR HANDLING UNIT (OVER I0,1300 CFM) EXHAUST HOOD(WMUMO HEATING UNIT (TO 100.00fir BTU) HEATING UNIT (OVER 100.1100 BTU) VENTILATION FAN (SINGLE RFSID) BOILER - COMP CHIP OR 100,000 BTU BOILER - COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ, FT. FEE FEE SUMMARY n BUILDING DIVISION FEES PLANCHECK FEE GRADING FEE SOILS FEE FENERGYFEE Date Reec le BUILDING FEE SEISMIC FEE. ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUM [ON 'rAX PAID Date AUG 15 Clry�r t,urry994 ISSUED BY: - 1�