275332
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SLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PY OF CUPERTINO APPLICATION/PERMIT PLUMUB N2-MECHANI
BUILDING DIVISION-,d—&,moA.S,zRrnt nwc Pnnfecr mmrrr
CONTACT: PHONE:
4cf-ai If 7* Ieg)f
LICENSED CONTRACTOR'S DECLARATION
2CZ I hereby affirm that l am licensed under provisions ofairpter9(commencingwith
J00 Section 7") of Division 3 of the Business add Professions Code, add my license is in
VEfull force and effect.
OZtu License Class Cut.—�.�
Eby Li Contrnctm
�yZ ARCHITECTS DECL ON
I understand my plans shall be used Is public reemde
:W
e �,, Licensed Professional
eox< OWNER -BUILDER DECLARATION
? a F 1 hereby affirm that 1 oro exempt from the Conaeadn s License Law for the
.erGr following rinsed. (Section 7031.5, Business and Professions Code: Any city ardently
• y J which requires a permit to construi alto, improve, demolish, or reMr any saucmn
3'f Printed its issuance.0.requires the applicant fmmch permitm file ssigndswement
e
:no than he is Iicensel pursuant on the provisions of the Conaecrda Liana law (Chapter
ICE 9(commeming with Section 7000) of Division 3 of da, Business and Profesions Code)
;_y m that he is exempt therefrom artd the basis for the alleged exemption My violation of
•Zoe Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of
C trot mon than five hundred dellen ($500).
3 $ ❑ I.uownerofthepmpetry,mmycmployeeawith wagautheuwlecompensanor,
Nl do Professions
Code:
The turtisnci License
La dofmot(Sac 7014, BusWss
ad arty wh ons Cede: The orsCondidecon. License law dos tart apply to rt owner iof
s
property whobuildsorimpmvu Nemproandwho dminchwmk Mmselfed for We. If. ewneenployeu,provided dustsuchimpmvemmuamwtimrndedmofferdfor We.IL
howevew the have
the
b r improvement iehold a within or improve
omm efor than owner -
We.).ill have th<busden of proving that he did nm build or improve for purpose of
We.).
❑ I.n owmrof NeproPrny,emuclusivelyronasctin8 with liunscdcanaectnnm
e camovcr Be pmiect (Sec. 7040, Beside. send Professions Cod.:) The Cana.cusrs
License law doe not apply to su owner of property who builds nr improves thereon, and
who cc ntmcu fm such projectswith a contractors) licensed pun want to the Contractor s -
License Law.
❑ 1 em exempt under Sm. . B k P C for this Lemon
Owner pa e
WORKMAN COMPENSATION DECLARATION
❑ Thereby off thatl haveecertificam of consanno self-insurt,maaro0cvm of
oveWerken'Compene'. malumna macenifid wpythereof(See.3g00, lab C)which
n tllemplayaiuderthis permit`
Policy N
C/f
Company
❑ CertiFld ropy u hereby f hes
❑ Cenifiedcopyis filth wy�tiryy p ,fpdmwus . _
fllds section mpletd ifthe pen iefmormhmndedd.11im 5100)
or leu.) "'•
I ccN at in ormema of thew fa which Ws Permit 1. iuud, label
not employ i any manler m to become mbjat m the, Workeri
Z Compensation Ice of ifomia Det
Api, t
0 0 siOTICETOAPPLIC :If.eft ' g this Certifirneef Exemption, you then-Ii
F►accomesubjeetoothe Wo sC ewti
ponp routtMLabor
ofCade.youmut
a , fmthrwith comply with such ..iron or this permit shall be deemed rtvolood.
0.A CONSTRUCTION LENDING AGENCY
Z) Z Ihereby aft tan them ise cwnnvction lending agwey fm the pcn. of
U p the work for which this permit I. i»ued (Sce. 3097, Civ. C.)
Ik. Elarder's Name
Q lander. Address;
W 1 certify that I have sed this application and sun tlut the above information is
cement. I agree to comply with ell city and county eminame a anti slam laws relating an
E•' rA building construction, and hereby auNodm reprtswmtivm of this city in uta upon the
U Z above-mettiortd property fee impaction purposes.
(We) agree to save, indemnify and keep hsmth<u the City of Cupertino against
IudiIylf-s•judgment, antsandF pcnus which may in any way accedeagaWtsaid City
HAZARDOUS MATERIALS DISCLOSURE
Will the vppli<ent or future building occupmt nom or handle ha drdom mamdW
as defined by the Cupertino Municipal Cade, Chapter 9.12, end the H.Wh and Safety
Calle, Section 25532(a)?
❑ Yen ❑ No
Will heapplicentm(murt buildingoaupantumequipmentordevicnwhichemit
hazardo s air contaminant as defined by the Bay Asea Air Quality Management
Didtria7
I ❑ Yu ID No
1 1 have red the hazardous mmesinie requir.ments under Chapter 6.95 of the
Zenon Health R Safety Code, Sections 0505, 25533 and 25534. 1 understand that
he building does not currently have a tender, that it is my responsibility to notify the
mpvm of rhe rcquiremems which must be mer prior to issuance of a Certificate of
cupency.
f
1 mer m ailluntod agent Dam
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPEC W. CIRCIIIT/hU5 C.
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
9UTLEM - SWITCHES -FIXTURES
NEW RPSIDENf1ALELECIR _SQ.FT.
PERMIT ISSUANCE I\
ALTER -DRAIN& VENT -WATER A)
BACK OW PROTECT. DEVICE
D INS - FLOOR ROOF.A ONO.
XTURES -PER TM
GAS -EASY C ouFUDT5
rsw
OAS -EAS 1Q VER4(EA
G TRL WASTE PfOR
P ( —
S S Y. E.A. 200".
WATER TER W/VENT/ELECM
WATER SY TING
NEW RESIDkMAL PLMB. SQ, PI'.
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER Ig000 CFM)
EXHAUST HOOD(W/DUCTT
HEATING UNIT (TO I W,000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP OHP OR 100,000 BM
BOILER - COMP (OVER 100.000 BTU)
NEW RESIDENTIAL MECH, SQ. Ff.
='A
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONT
:y
PAID
Data ReceiptN
o
ci�yGF .1019
9S
1p1996
rCh•/%y
ISSUED BY:
2753:
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SANITARY NO.
I APPLICATION SUBMITTAL DAI
NO:
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CONTROL N`
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PLUMB ME❑CH
JOB DESCRIPTION
SQ. FT. FLOOR AREA
13f5o
$6Q. PT. .
GVALUATION
J� g 7 66 ^�
='A
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONT
:y
PAID
Data ReceiptN
o
ci�yGF .1019
9S
1p1996
rCh•/%y
ISSUED BY: