24936APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINOBU I[.DING-ELECT HICAL PERMITNO. 2 4 9 3 6
APPLICATION/PERMIT) PLUMBING - MECHANICAL.
BUILDING DIVISION BUn neer. iii i Inem'puvAnnN it
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LICENSED CONTRACTOR'S DECLARATION
I hcrcby tffnn thut 1 um liwnced undcrpnsvlsionsnfChupter9 (commencing with
Swoon 7000) of Division 3 of the Business and Professions Code, and my license is in
full force unite r
c. Q% :O
I.icar lass . 3 Lie.0
Date V Contractor t 4
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records.
OWNER -BUILDER DECLARATION
I hereby affw that 1 am exempt from the Commcmr's License Law for the
fallowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires apeman to construct, aper, improve, demolish, m repair any swre
mu
prior mils issuance, also requires the applicant for such pmmil fileasignedsmmmeal
that he is licensed pursuant o the Provisions of the Contractors License Law (Chapter
9 (commencing with Section 7") of Division 3 or the Business and Professions Code)
m that he is exempnherefrom and the basis mons, alleged exemption. Any vinfronn of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollars (5501).
❑ I. asownerol the property. or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 70cf L Business
and Prolessiom Codec The Contractors License Law does not apply to an owner of
property who build or improves rberean. and who does such work himselfor through his
oemployers, provided that such improvements are not intended orofinered for sale. If.
however. the building orimpravnment is sold within one year ol'completion. thocosam-
builder will have the burden of pmving that he did not build or improve for pugose of
sola).
❑ 1, as owner offs, property, onexclusively contracting with licensed coatmnorsm
answer the project (Sec. 7044. Business and Professions Code:) The Contractor's
License Law doesnorapply roan owner deropcoy who build..,m improves thereon, and
who contracts fur such prejals with a conwnogs) licensed pursuant to the Condolences
License Law.
❑ l am exempt under Sec. . B & P C for this reason
Owner Dan.-
WORKMAN
ateWORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a cenifcate ofcometn to sel6imxure, nr a pnifcara of
i Wrukeri Compensalinn Irvsomnee or a eonif ed copy thereof ($ec Ag011, Lob C.J whidr
-' covers all emplec�� yyppdu rA sp5n�y1, C? -I--
-
Policy# IOs J- 1e. 3iJ
Company
❑ Ccnifedcopyishcrcbyfumishcd.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if rhe permit is foronc hundtNdallars (SIM)
or Ica,.)
I ,unify that in the perfomwoce ofthe work for which this permit is issued, l shall
.of employ any person in any manner so as to become eubjW to the Workers
Compensation Lwsnf Celifomin. Date
z
Applicant
z NOTICE'I'O APPLICANT: If, after making this Cenlficare of Exemption. you should
E-' become subject to the Worker s Compensation provisions of the Labe Code, you must
> forthwith comply with such Provisions or this .it shall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
Z
I hereby offer bn there is a conswmion lending agency for the performance of
U 0 the work for which this permit is issued(Sec. 3097, Civ. C.)
lenders Name
Lr~ F 1<oders Andreas
U 1 orally that I have read this application and state that the above information is
>-' Lk1 correct, l agree to comply with all city and county ordinances and state laws relating to
H building construction, unit hereby outhrrice representatives of this city to enter upon the
UZ above mentioned property far inspection purposes.
(We) ogr to save, indemnify and keep harmless the City of Cupertino against
liabllirics,ju tents. casts suniWpeoses why may in any vs�,y accrue against said City
41 —P �S
7&tfi=�to�blha
anVComUs' DamHAZARDOUS MATERIALS DISCLOSURE.cmn or future building occupant store or handle hmardous material
upenino Municipal Cede. Chapter 9.12, and the I lwlth and Safety
2(u)7 ❑ No
Wil l the applicant or future building occupant use equipment or devices which emit
laairma oua air contaminants nts as defined by the Bay Area Air Quality Management
IYVIet7
❑ Yes ❑ No
1 have read the hamrdous materials requiremems under Chapter 6.95 or the
California Health & Safety Cate, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant. that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate or
Occupancy.
Owner or authorized agent Data
LOTH
LIC b
Fore 29;
KS fits/2 eA1�s 2wc-
ELECTRIC PERMIT
P17RMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS
UP TO 20) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC. tat
TEMP. METER OR POLE INSI. �.-
POWER DEVICES
SWIMMING POOL ELECTRIC D
OUTLETS - SWI I CUES - PIXI'URES`--
NEWRESIDF.NTIALELECTR SQ. FT.
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTEC9'. DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLET'S
GAS - EA. SYSTEM -OVER 4 (EA)
GREASEiINDUS RL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 201
WATER HEATER W/VENT/ELECfR
WATER SYSTEMITREATING
NEW RESIDENTIAL PLMIL SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UND (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 1(L000 CFM)
EXHAUST HOOD OODUCI)
HEATING UNIT (TO 100,00W B'TU)
I [EATING UNI "1(OVER 100,000 BTU)
VENTILATION FAN (SINGLE. RESID)
BOILER - COMP CHP OR I0U.000 BTU)
BOILER - COMP (OVER 100.000 B -TU)
NEW RT:SIDI7N'1'IAI. MECI I. SQ. FT,
OFFICE
r'A
FEE
FEE
FEE
CAAA3
BUILDING PERMIT INFO
BLDG ELECT PLUMB
❑ ❑ ❑
F� IN "I
I-_ R
FEL, SUMMARY
PLANCI IECK FEE
GRADING FEE
SOILS FEE
ENERGY IEE
PAID
Date Rmaq,N
TOTAL:
BUILDING FEE".
SEISMIC FEE
ELECTRIC FEE
PLUMBING PER.
MECHANICAL PTE
CONSTRUCTION TAX
PAID
Date Ramona p
.
(� "T
P W J O
APR .ry