25671APPLICANT TO FILL IN INFORMATION WITHIN RED LII
CITY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
' / 90 / Def K v/41L cN.
JNER..ppME: 111IONE:
LICENSED CONTRACTOR'S DECLARATION
CKZ Iherebyalfnr'hat l am licensed underprovisium of@aplef9(commencing with
FOOF� Scnlmn 9(IOIBof Division 3 ofthe Business and Professions Code, and my license is in
�ZU fall farce anJ elle°i Sum 7S'f
I<„Lm Lice las Lic.M
ao<o. ale Contractor
ZONE ARCHITECTS DECLARATION
O Z—❑ I understand my plans shall be used es public records.
Licensed Professional
<
ER
ae
C �< OWNER-NUILUDECLARATION
kOaU 1 hereby affirm Lha' 1 in exempt boon the Contractor's License Law for the
yLLO1- following reason. (Section 9031.5, Business and Profusions Code: Any ciOf,of, county
J which inquires a Permit to consumer, Wier, improve, demolish, be helium; ny sweture
5E}7 prior to its issuance, also requires the applicant for such Permit to file a signed statement
W <Oy� Lha he is licensed pmsuanr to the provisions of the Convectors Licrnu Law (Chapter
'agoW 9(commencing with Section 7") of Division 3 of the Business and Professions Code)
XW—m or that he iv exempt herefrom and the basis for the alleged exemption. Any violation of
=ZQ Section 7031.5 by any aMlicare for a pewit subjects the applicvnureacivil Penalty of
net more than five hundred dollars ($50J),
�Fp ❑ I, as owner ofthe pmpeny, or my employees with wages as their sole compensation.
n3— wRldodlewark.andtheswctumisnurinrendedoroffe for We(Sec.)04M1,Baslneas
and Professions Code: The Conumemr's License law does not apply to an owner of
own
em who buildsor improves Ih improvements
mpr andwho docssuch work himulfor through his
employees provide) provehimpnwom wit in ne intended completioreofferedn.
thcala.IL
however,the
have
etbuildie brimpmvcmenl issoldhe id noneyar or rept cfa,Nrposeo-
builderwill huve'hc burden of proving that be did not buil) or improve for purpose of
sale.).
❑ Las owner ofthe property, ern exclusively contracting with licensed convectors to
construct the Prot. (See. 9044, Business and Profeasirms Code:) The Conarecmr'a
License Law does not appl y loan owner o f property who builds m improves thereoa, and
who creatures forsuch projects with a comwemr(s) licensed pumuanuo the Contractor's
License Law.
❑ 1 an exempt under Sec. . B & P C for this reason
Owner Data
WORKMAN COMPENSATION DECLARATION
❑ Ihershyieffirmthat l have acerificateofconsent to self-insum,macertifcateof
Workers' Compensation Insurance or a certified copy thereof (Sec. 3800, lab C.) which
cvers all employee's under this permit.
Policy a
Company
❑ Certified cagy is hereby furnished.
❑ Certified copy is filed with de city inspection division.
C12RTIRCAM OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be compleml if the permit Is for one hundred dmllars($100)
or less.)
1 certify, that in the perfowar. of the work for which this Pewit is issued, I shell
not employ any Perm in any regular w ses to become subject to she Wotkeri
Z cisn'suni.nlawaof Califomiti. Date
0 Applicant
7 C) NOTICE. TO APPLICANT: If, after making this Certificate of Exemption, you should
Frte. become subject In, the Worker's Compensation provisions ofthe palter Code, you must
> lrertbwim comply with such provisions or this permit shall be deemed revoked.
1 Q CONSTRUCTION LENDING AGENCY
7 z Ihereby affirm that there is a construction leading agency for the performance of
U O the wreak for which this pernir is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
U 1 certify thin I have read this application and state that he above information is
>i w correct. I agree it) comply with all city said county orifinearces said state laws health, to
F-' building mnswesion, and hereby auNorie, expacscnlatives of this city 1. enter upon the
U Z above-mcmioned proi for inspection puaposi
(We) agree to save, indemnify and kap harmless the City of Cupertino against
liabilities, judgments, casts and expenses which may in any way accrue against said City
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store Or handle bavardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 255320)?
❑ Vic, ❑ No
Will theapplicant orfutumbuildingoccup rat useeyuipmem ordevices whichemit
aua t�as air anaminants as defrod by the Bay Arta Air Quality Management -ismirel
❑Yes ❑ No
1 have rcud the hnaardim, materials requiremcnb under Chapter 6.95 .1 the
Califomia Health & Safety Chile, Seniors 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenser, that it is my responsibility to notify the
caption of the ra'airerrcms winch mast be met prior to issuance of a Cenificae of
Occupancy.
Owner or amhorimed agent Date
PLUMBING -MECHANICAL
LOTH
/O T T/ 15~
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201-1000
OVERI00o AMPS It"I'l
TEMP. METER OR POLETsIST, V
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEWRESIDENTIALELECIR SQ.FT.
4-71
11- 2-5671
ON
SANI TARY NO.
APPLICATIONSSUBMI-PIIyAL DATI
Lo - 2 f ` l3
.IC NO:
N/C
❑
CONTROLa
u AIF CNS
FEE
.BUILDING PERMIT i NFO
LDG ELECT PLUMBMSCI
FEE SUMMARY
JOB DESCRIPTION
OUTSIDE BELS
Ill. FLOOR AREA
)
SANITARY
Y N
ali
TEMP. METER OR POLETsIST, V
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEWRESIDENTIALELECIR SQ.FT.
4-71
QTY: PLUMBING PERMIT FF.E
FLOOD'J.ONF.
APN
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
OUTSIDE BELS
BACK FLOW PROTECT. DEVICE
SANITARY
Y N
RECfi1P a
DRAINS-FLOOR.ROOIr, AREA,COND.
SCHOOLTAX
Y N
RECEIPT p
FIXTURES - PER TRAP
PARK FEE
YN
RECEIPT N
GAS - ISA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
GAS CA. SYSTEM-OVER4EA)
PLANCHECK IEE
GREASMISDUSTRI. WASTE INTERCEPTOR
GRADING ITE
GREASE TRAP
SOILSFEE
SEWER - SANITARY - S'TORM EA. 2001''.
ENERGY FEE
WATER HEATER W/VENT/I.LECTR
PAID
WATER SYSTEM/IREATINC
Date
Receipt#
NEW RESIDENTIAL PLMB, SQ. ET.
TOTAL:
MECHANICALPERMIT - FEE
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR IIANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT(OVER 10.000 CFM)
EXI IAUST HOOD (W/DUCT)
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100.000 BTU)
VENTILATION FAN (SINGLE REST D)
BOILER - COMP OHP OR 100,000 BTU)
BOILER - COMP (OVER 100,(100 BTU)
NEW RESIDENTIAL MECII. SQ. FT.
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECI IANICAL ITE
CONSTRUCTION TAX
PAID
Dae
ISSUANC17 DA TE
PAID
OCT 25 1991j,�
ISSUED BY'