27534CI'T'Y OF CUPERTINO,
BUILDING DIVISION APPLICATION/PERMIT
PHONE:
LICENSED CONTRACTOR'S DECLARATION
nuz Ihefehyaff ilthm lam licensed undefpmvisinnsnfChnpmr9(commencingwith
.100 Section 700d).f Division 3ofthe Business and Profusiam Cade,mv1 my license is in
FK W full forte and affect.
62Vy, y1 Lima. Class Lo.N
h<y Date Contractor
,Z �,?s ARCHITECTS DECLARATION
oz_Q I undcrstand my plans shall be used as public records.
FHkw,
<Y:E, Licensed Professional
ad
:'=< OWNER -BUILDER DECLARATION
XOEF I hereby affirm that I am exempt from the Connector's License Law for the
W 3 W m¢ following reason. (Section 7031.5, Business and Perfusions Cade: My city or county
F L'ONJ which require a permit to conswct,alter, improve, demolish, of repair any structure
yr�Qi prior to its issuance, also «yures the applicant for such yennit to fi he a signed statement
W ES
no that he is licensed pursuant to the provisions of the Convector's License Law (Chapter
d xaadoE 9(commencing with Section 7") of Division 3 of the Business and Professions Code)
y)_m or that he is exempt therefrom end the basis for the at legal exemption. Any violation of
Section 7031.5 by tory applicant for a permit subjects the applicant m a CIA penalty of
I $ G
nte t mothan five hundred dollars ($500). .d
t1' � ❑ 1, us ownerofthe pmpeny, or my employees with wages as their site compensation,
ES., will do the work, and the structure isnot intended or offered forsale(Sec. 711,4, Business
and I'rrl'essions GNe: The Contractor's License Law docs riot apply to an owner of
property who builds err improves thereon, andw mike, such work himxll'onhou"hbis
own employees, provided that such improvementsure not intended proffered tursulo. If,
buweseq the building or improvement is sold within one yearofcomplmion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owneroRhepropeny. amexclusively contracting with limmmd eanvactonto
construct the project (Sm. 7044, Business and Professions Cale:) The Contractor's
License law does not apply to an owneroffampeny who builds or improves thcrom,and
who contracts 1br such pmjorts with a contractor(.) licensed pursuant to Contractors
License law.
❑ 1 sum exempt under Sec. , B & P C for this reason
WORKMAN COMPENSATION DECLARATION
pp I hereby affirm that l have a certificate ofcommin to sel4inaa or a coni ficarco
..brkers'Compensation insurance wacertifiedcopy thereof 800,Lab C.)which
1 casco all employee's under this permit.
Policy #
❑ Certified copy is hereby furnished.
❑ Cenificdcopyisfiledwiththe city impecti division.
CERTIFICATEOFEXEMPTIO FROMWOR S'
COMPENSATIONINS RANC
(This suction hired not be completed ifthe be Itlsforit I ...ORB)
or less.)
I certify shot in the performance of the work fur hichthispem if, traLIshn11
not employ any person in any manner so as too.m
sumb subject I c WAerd
ZCompenLaws of California. Dam
Applicant
Z O NOTICE TO APPLICANT: IL after making this Certifca of Exemption, you should
r IzI benune subjenmthe Worker's Compemasion pmvisiomo he Lodn Cwlgyoumu
R forthwith comply with .such Provisions or this permit shall toed revoked.
dQ CONSTRUCTION LENDING AGENC
Z Ilambyaffirmthat there iso construction lending agency fur pc ..of
U O the work for which skis permit is issued (Sec. 3097, Civ. C.)
Li.
lender's Name
I^ Lender's Address
V I cenify that I have read this application and male that the above information is
correct. l agree to comply with all city and county ordinances and state laws misting to
F'' y building construction. and hereby authorise represented ves of this city to enter upon the
V Z BbovcmcmioneJ property for inspection purposes.
We, agree to save, indemnify Bad keep harmless the City of Cuponiro against
liabilities,judgarents, cosh and expenses which may in any way accrue against S id City
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant at future building occupant store or handle haxurdous material
as defined by the Cupar ino Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532(.)1
❑ Yes ❑ No
Will the applicant or future building weupant use equipment or devices which emit
hamdous air canmminants as defined by the Bay Area Air Quality Management
pistria4
❑ Yes ❑ No
1 have mad the huvrdous materials requirements under Chapter 6.95 of the
Califomie Ilealth & Silety Code. Secdons 25505, 25533 end 23534. 1 understand that
if the building does not cumently have a tenant, that it is my responsibility to notify me
cupant of the rcquir ments which must be at prim to issuance if. Ceftifiome of
Occupancy.
Owneror awhnriud a gent - Data
PLUMBING - MECHANICAL
FEESUMMARY
BUILDING PRIIJECIIDKN'I'IPICA'1']ON
LOTH
SANITARY NO.
�c"fOR'S NAM -E: 1 LICNO:
was PK I
�CA.OT'�I
"'G
RECEIPT#
o.
ELECTRIC PERMIT FEE
BUILDI.
BLDG ELEC
EJ
PERMIT' ISSUANCE
APPLIANCES - RESIDENTIAL
IOIi
PANELS
UPT02MAMPS .
SIGNS ELECTRICAL
SPECIAL CIRCUI UMISC. '
TEMP. METER OR PULE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES . NXTURIS
NEW RESIDENTIAL. ELECTR —L
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF. AREA. GOND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
AS - EA. SYSTEM OVER 4 HLA)
P ASE/INDUSTRL WASTE INTERCEIH'OR
GREA ETRAP
SE R -SANITARY S RMIIA.20017 '.
,WATER HIiATE0. WNENT/IiI.ECTIt
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ. hT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR AUD'I'O MSCI I.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,(99) CPM)
EXHAUST HOOD (W/DUC1)
HEATING UNIT (TO 100,0110 B U)
HEATING UNIT (OVER 100,0110 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP QHP OR 100,000 BLV)
BOILER - COMP (OVER 1110,01X) BTU)
NEW RESIDENTIAL MECH.—SQ, FT.
TOTAL:
FEE
a Y/
27534
br
BUILDING FEE,
SEISMIC PER
ELECTRIC ERI?
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Data
PA10
FEB 91995
.i
CI\II I vrr i urcHQ'TOS71
By
FEESUMMARY
OIJ1SIDIrFLT=,
SANITARY
Y_N
RECEIPT#
rCHOOL TAX
Y _ N
RECEIVE'#
PARK FEE
Y N
RECEIPT It
BUILDING DIVISIONF
PLANCHECK FEF.
GRADING FEE
SOILS IEE '
ENERGY PEE
PAID
Data
Receipt
BUILDING FEE,
SEISMIC PER
ELECTRIC ERI?
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Data
PA10
FEB 91995
.i
CI\II I vrr i urcHQ'TOS71
By