28126CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
G
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1atn licensed under provisions of Chapter9(commrncing with
Section 7") of Divi ,ion 3 of the Business and Profession Cade, and my license is in
full force and effect.
License Clan Lic. N
Doc Cmarector
ARCHITECTS DECLARATION
1 understand my plans shall h used as public ree mis.
Licemed Pmfeseional
OWNER -BUILDER DECLARATION
I hereby dfmn thio I am exempt Tram the Comnctors Littme Law for rhe
following memo. (Section 7031.5. Business ad Profession Cade: My city ce county
which requires o permit in consumer, alter, imptave. demolish, ne repair any atmetore
prior to its issuance, also requires the applicant for such peanut 10 file a signal ..Out
Out he is licensed pursuant o the provision of the Conotcmrs License Law (Chaps,,
9 (commencing with Section 7")of Dimum3 ofthe Business std No(nsiss Code)
Or Net he is bxeanpt therefrom end the basis for the alleged exemption. My viaticum of
Seen. 90313 by my applicant for • permit subjects the epplinm to a civil pemlty of
nor muse Gun rive hundred dollars (5500).
❑ I.nownaofthepruperry,mmYmploymwithwaltnnthcvulecompnsdm,
will de the wort. ad the menage is not inuMd orofferN forsde (Stc.704PL Business
sent Pnofmions Code: The Commerce. Liceme Isw don too apply to re owner of
propcM who build, or improves dermn, and whodm such wart himselfmthrough his
rom cmploym, poinki dutauch imprevemenu ere not intended or oRead for We. if.
however, the building or improvurcnt is sold within one Yen ofcompletion.theowner-
builderwillhavethehurdcnofprovingshathedidrot 0 prove is purpose of
sale).
❑ I,nowruroftheproperry,amexclusiveiycm gwith Bc conmcmnre
comvuct the pmjes (Ss,. 7014, Basions, and fessisu Code: The Con thatch s
LicmnLawdaamnpply toanowmrof whobdW aim verlMeon.W
whocanoacnfasuchpaj«is withecom s)Bamd pursumn ConmanMa
License Law.
❑ 1 ten exempt under 4 . B h P C m thisratan
I herebydBrm U(aol eecerdfsnmofcmum
ran, Com ance s
ms, cacftdcopyO
s all empl ,under this pmem.
Policy N
Company
❑ Cmifrd c pry is hereby fu
❑ Cerifid pry is Bled with
(Thissecti Lffcd tlptlk completdifdrepesmit iaf Tone mmtmed aolun(sowl
m len.) .T
I ttnify the in the pa my ma nen so fs 'cFNubjet. ct n issued.tWoehdl
rou employ my ram N any manner soy roes my nV
nx subject m rhe Wohai,�bjeet m the Wgkai
Compenmion sof California. Date
ZZ Applicant
0 NOTICE TO AP: If, alta matin u Certificate of Exmptim, you should
becgnesubjealAc".Compes m pmvisian of the lobar Code. You mus
a >
forthwith complyh provisiam N,paNtduB be demrd mokd.STIR ON LENDING AGENCY
Lherebyafh a canawctim lending agmry far rhe PaBNnwneof
U p du work far which this pence, is issued (S«. 3097, Civ. C.)
Lenders N.
O Lenders Address
I certify wt 1 have read Ns appllcatim winsi this Or above infamldim i,
>. 1 corrtq. degree ocanply with Vl city endromryordineraa send mete I.W. reldngm
f-' buildingcrosouctim. and hare!y suthariu regexnutivesaf this cityomteruponthe
V, Z above-mcmiond property for impectim purposes.
(Wc) eg ysy nvc. indemnify std keep Iwm Ne CIry of Cupm m sgaims
I HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fume building occupant tom or hurdle hasardoua rounnoel
as defined by the CuNnino Municipal Code, Chapter 9.12, and the Hold, end Safety
Cod, Section 25532(.)?
❑ Ycs ❑ No
Will the applicant or future building occupant useec, ipmentahviceswhichemit
hnardous air cmuminses u defined by do Bay Ant Air Quality Mwgement
District?
❑ Ycs ❑ No
T hove and the harvduus marrfuH ro,ireroms under Chapter 6.95 of he
Celitomia I health,& Safmy Cw,. Scaimrs 25505.25533 and 25534. 1 understand that
It rhe hmiding doe, not c.rremly have a term, that it is or, rtxpun.ibiliry m ..if, de,
cupam of the rryuiremenu which must be mer prim to ismmae of a CeniGene of
(kcuparu_
Owner or authonud u8em Data
- USE BALL POINT PEN ONLY
B IL MECHANICAL AL
PI,U1101NIT - MECHANICAL
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTEIMISC.
TEMP. METER OR POLE MSP.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES . FI(TURES
NEW RESIDENTIAL ELECrIt _SQ. FT.
PERMIT ISSUANCE
ALTER - DRAIN @ VENT- WATER (EA)
BACK FLAW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, GOND.
FIXTURES - PER TRAP
GAS -EA. SYSTEM -1 INC. N OUTLETS
GAS - EA SYSTEM-0VER 4 (EA)
GREASE/BIDUSIRL WASTE INTERCEPTOR
GREASETRAP-
SEWER - SANITARY - STORM EA. i00PT.
WATER HEATER W/VEHTIF7.F,CTR
NEW RESIDENTIAL ILJMB. SQ. FT
TOTAL:
PERMTr ISSUANCE
ALTER OR ADD TO MECH.
ADI HANDLING UNIT (TO I0DDO CFT1)
AIR HANDLING UNIT (OVER If." CFM)
HEATING UNIT (TO IOOA00 BTVI
HEATING UNIT (OVER IW." BTU)
VENTILATION FAN (SINGLE MID)
BORER . COMP (3HP OR IMODO BTU)
BOILER. COMP (OVER IM." BTU)
NEW RESIDENTIAL MECH. SQ. PT.
BURS
pLANCHECKFEE
GRADING FEE
SOBS JIBE
ENERGY FEE .IL
PAM
Den:
BUI DINGFEE
SEISMIC FEE
FIECIRIC FEE
PLUMBING q'E :�
PAID
he
`IS!
ISSUED
fRM.. 28126
SANITARY NO. APPLICATIONSUBMITTALDKIT-
�^)ILAS
NIC CONTROL
p
NO:
'*•' -
'BUILDING PERMIT INFO_,`o't.a'�i.�
qPLUMB MECH
❑ ❑
JOB DESCRIPGON
S u
SQ. FT. FLOOR AREA
7
57SQ. FT.
VALUATION
L
BURS
pLANCHECKFEE
GRADING FEE
SOBS JIBE
ENERGY FEE .IL
PAM
Den:
BUI DINGFEE
SEISMIC FEE
FIECIRIC FEE
PLUMBING q'E :�
PAID
he
`IS!
ISSUED