25321APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
BUILDING — ELE, rRTCAI-
CI BU OF CUPERTINO APPLICATION/PERMIT PLUMBING. -MECHANICAL
BUILDING DIVISION mrr.. e,+.., I'D"..................�...,.
LICENSED CONTRACTOR'S DECLARATION
nCz Ihereby affal thatI no licensed under provisions ofChap¢r 9(commencing with
B]001= Section 7000) of Division 3 aide Business and Prof e..I.. Code, and my Because is in
FFwut ful l forte and effect.
1a„Za1 License Class Lic.#
A<0- Dam Contractor
ZOtoz ARCHITECT'S
TS DECLARATION
O Z � I undersand my plans shell ed used ss spublic records.
6,y
n
Licensed Professional
L fY�6 OWNER -BUILDER DECLARATION
kO a V 1 hereby affirm that I am exempt from the Contractor's License Law for the
W3 a y¢ following mason. (Section 7031.5, Business and Professions Code: Any city or county
t R:Oy J which mgmres a permit to construct, alter, improve, demolish, or repair any swctu ,
ql!aa��
� Prime its issue .Ms. peritonea Bob wleard, I ... ch permit 1. file. si,mal statement
npenpursuant
z that he is licensed to the provisions of the Convectors Lica se, law (Chapter
aKeLL 9(commencing with Section 7000) of Division 3 of the Business and Professions Code)
or he ise.emp,therefrom and the basis fr,he total exemption. Any violation of
4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nre than five hundrul dollars ($500).
W m nm
❑ I, as ownerofthe property, or my employees with wages as theirsole compweotion,
6 _, will dmhewrk, Core: svucturcisnmimendeds Law redfr mapply]044,Bube,of
prJ Professions Cale: The ve& thane s Liana Law such
not apply to an owner us
pmpcnyw,ecaho . pdsoidedt1 vesthe prove whodmsmctaidedimmlrortlwughhi,
awnemployees,proviJaHhm sve improvemwanrene imendedoroffened Jambi.
however, Nebuildhe order ofpmemissoldwithinoneyear of completion, thrower
huedct will have the burden of proving that he did not build or improve for purpose of
ml<J.
❑ Las the Pr ject (Sec. 7 properly, Business
ely add contracting s Coonan sedTh Contractors
License License the project (Sec. ]f144, Business unJ Professions Cedeq The Camrector's
License trawdrano, apply ct an with
eco fproperty who sed puns impmvee thereon, cod
who contracts Law. for such projects with ewnuacmr(a) licensed pursuant Lithe Convadors
Lice se law.
❑ n1 ern exempt under See. , B & P C for this rcemn
WORKMAN COMPENSATION DECLARATION
,Cokeherebyaflism tont Ihoveacenificam of consentero(See, 38Br.ab C.) hoof
mrkctY Compensation Ire this p ora ernifiad copy thereof (Sec. 3800, Leh C.) which
Paters all employee's under this permit.
Policy M
Company
❑ Cmifiedcopy is hereby furnished.
❑ Certifiedcopy is filed will Ne city inspection division.
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section mordant be completed if the permit is forane hundred dollars ($100)
or less.)
I certify that in the Performance of the work for which this permit is issued, l Shull
not employ any person in any manner mss to become subject to the Workers
z Compensadenlawsof C.lifomia. Dam
Applicant
0 NOTICE TO APPLICANT: If. after making this Cenificam of Exemption, you should
In become subject at the Workers Compensation provisions of the labor Code, you must
Chi
forthwith comply will such provisions or this permit shall be deemed revoked.
W CONSTRUCTION LENDING AGENCY
z
•^a I hereby affirm that hem is a construction landing agency for the performance of
Othe work for which this permit is issued (Sec. 3091, Civ, Cl
CT. Ixnder's Name
OLenders Addre
U ss
I certify Net 1 have mad his application and Sam that the shove information is
corl l agree to comply with all city and county vrdinsnces and sure laws misting to
building construction. and hereby ao,honm representatives of Nis city to enter upon the
V abewe-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
linhi li ties, judgments, casts and expenses which may in any wq accrue againsl said City
(/HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant nom or handle hazardous mutenal
as defined by the Cupertino Municipal Code, Chnpler 9,12, and the Health and Safely
Code, Section 25532(x)]
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which emit
nus air conamin m; as defined by the Bay Area Air Quality Management
❑ Yes ❑ No
I have read the atone ur materials regtiremcnb under Chapter 6.95 of the
California Health & Sofmy Cede, Sections 25505, 25533 sad 25534. 1 understand that
if the holding does not cm emly have a tense,, that it is my responsibility to ratify the
occupant of ,he requirements which mus, be me, prior to issuance of a Certificate of
Owner or authorized agent Data
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMINO POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECT# _SQ. FT.
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (FA)
BACK FLOW PROTECT. DEVICE
DRAINS - BOOR, ROOF, AREA, COND.,
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLET'S
GAS- FA. SYSTEM -OVER 4(EA)
GREASIONDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA, 200111'.
WATER HEATER WNENT/ELECI R
WATER SYSTEM/GUTATING
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLI NO UNIT (TO 10,000 CIrM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUSTHOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 100,0(10 BTU)
VENTILATION PAN (SINGLE AKSID)
BOILER - COMP (BHP OR 100.000 BTU)
BOILER - COMP (OVER 100,000 B'N)
NEW RESIDENTIAL MECH. SQ. FT.
25321
SANITARY NO. APPL1CATION SUBMITTALDATE
-l'S-43
N/C CON TROL#
FEE BUILDING PERMIT INFO
r@LDG ELECT PLUMB MUCH
t�-p( ❑ ❑ ❑
��
�.a JOB DESCRIPTION
UQ.\P()UJVS
R $/SQ. FT.
pUTER
D C
VALUATep
STORIES TYPE CONST RUMON
OCC.GROUP RES. UNITS
FEE FLOOD ZO 1. APN
FEE SUMMARY
E FEES
SANITARY Y N
RECEIPT
SCHOOLTAX YN
RECEIPT p
PARK FEE YN
RECENT#
BUILDING DIVISION FEES
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Data Receipt#
FEF?
BUILDING FEE
SEISMIC FEE
ELECTRIC PEE
PLUMBING FEE
MECHANICALFEE
CONSTRUCTION TAX
PAID
Data
OCT12
r e.
ISSUED BY: 01