26212(CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECIIANICAI.
BUILDING DIVISION BUILDING PKOJKCIIDENI'IEICATION 26212
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RCIII'rECT/FNGINEIiR: LICNO:
ONTACT: PHONE:
LICENSED CONTRACTOR'S DECLARATION
yz
Ihcmbyaffnn thm l sum licensed under provisiomofCAxpicr9(commencing with
Rm Sectionlatudnf Division 3 of the Business and Professions Cole. and my license is in
95w full force and effect.
FzLicense Clas Lica
m y DmexContracmr
zc)yK ARCIIITEC sDF.CLANATION
OZ �Fz 0 1 understand my plans shall be used m public records.
F,,otcd Licensed Professional
OWNER -BUILDER DECLARATION
5pd,04I, 1 hcmhy affimr that 1 um exempt form the Contractor's License Law for the
Y7 E>• 4 V1 following rcasom seelion 9031.5, Burmcax and Professions Code: Any city or county
F—ESC'S which requires a permit to construct, alter, improve, demolish, or repair any structure
}� prinno its issuance, also requires the applicant for such Permit to rile a signed statement
<C) that he is licensed pursuant m the provisions of the Contrach.ex License Lew (Chapter
440' 9f,rnmencing with Section9W0)of Division Sof the Businessmrd Professions Code)
_y or that he is exempt therefrom and the basis for the alleged exemption. Anyvidmion of
�QSection 7031.5 by any applicant for o permit subjects the applicant to a civil penalty of
9 pnot more than five hundred dollars (551111).
� $ ❑ I,asoweerofthepmNmy,ormyemployeeswithwagesastheirsolecompensafon,
4 will do the work,und the stmnum is not intendederoffcied forsele(Set. 7044, Busineas
and Porfesa rs Code: The Commemis License Law does not apply to an owner of
propertywboloddsorimproves thereon, andwhodms such work himselforthroughhis
owncroployces,proyidial thatsuchimprovemen sant not intendeduraffertd forsal, If,
however, no buildingor improvement is sold within one year of completion, the owner.
builder will have the burden of proving than he did not build or improve for purpose of
bole.).
❑ Lasnpr
roftheoMrty,amexclusivclyconumt gwhhiicensedcon"a tanto
commue, the
project (Sec. 9044, Business and Profess us Code:) The Contractor's
License Lawdocs nmapply to an ownerofpropeny whobuilds or na movesthereon, and
whountmcts forsuch projects with.contraetogs) licensed product tothe Conumtofs
License Law.
❑ l am exempt under Sm. , B & P C for this moon
Owner Das
• WORKMAN COMPENSATIONDECI-ARATION
❑ Iherchy affirm
WORKMAN
ve COMPENSATION
DETorelr-insure, oro cenifcorc of
Workers Compensation Introduce macertifol copy thereof (Sec. 3800, Lab C.) which
covers all employee' made, his permit.
Pulley p
Company
❑ Cenifedcopyisherebyfumished.
❑ Certifedcopy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone, hundred dollar (5100)
or less.)
I eerily that in the performance orthe work for which this Permit is issued, l shall
Z Qmploy p son in any manner so a to become subject to the Worker%
eentrain� 1 four i1r, e
O O CoPPIic
NOTICE. hICANT: IL after making thm Ce cart of F.xe n, you should
F V) become soh' to the Worker's Compcmxtion prov mm of th r Cade, you must
a 1 forthwith ply with such Provisions or pernit shall bedrevoked.
1 Q CONSTRUCTION LENDING AGENCY
U z I herchy affrm than hem is a censbuctioth
n lending agency for e performance of
O the work for which.his pmom is issued (Sec. 7097, Civ. C.)
L1. r.1 Ixndels Name
O ULender's Address
W I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
ybuilding comwction, and hereby authodre represemmivm of this city in enter upon the
U7
C above-mentioned pnspetty for inspection purposes.
(We) agree to save, indemnify and kcep hmmlas the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way neer a against said City
/ HAZARDOUS MATES7f ACS DISCLOSURE
Will the applicant or future building occupant store or handle h.randous material
as defined by the Cupertino Municipal Cod , Chapter 9.12, 4nd the Health and Safety
Cade, Section 25532(.)?
❑ Yes ❑ No
Will the upPlicnmorfutumbuildingoccupantuse equipmenmrdevicas which emit
hamddous air contaminanD as defined by .he Bay Area Air Quality Maxagemcut
Districs7
❑ Yes ❑ No
1 have read the hamolms materials requirements under Chapter 6.95 of the
California Beahh & Safety Code, Sections 25505.25533 and 25534, 1 understand that
if the building does not currently have a reams, that. is my res mobility to notify the
occupant of the requirements which must be met prim to issuance of a Cenificme of
Occupancy.
Owner or authnriced.,a, Date
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2M AMPS
201 - IM AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MIISC.
1
TEMP. MEIBR O0. P Li
s� �
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR —
SQ. IT.
TOTAL:
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - GRAIN & VENT- WATER (BA)
BACK FLOW PROTECT, DEVICE
DRAINS. FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - P.A. SYS 'I RM -OVER 4 HDo
GRBASEONDUSTRI, WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 201
WATER HEATER W/VENT(RLECTR
WATER SYSTEMITREATINO
NEW RESIDENTIAL PLMB. SQ. FT.
MECI IANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR IIANDLING UNIT (TO I0,M CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WJDUM
HEATING UNIT 00 Inc." BTU)
HEATING UNI'( (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
BOILER - COMP 0HP OR I0q,(If10 ITT U)
BOILER - COMP (OVER 100,IX0 BTU)
NEW RESIDENTIAL MIiCH. SQ. FI'.
TOTAL:
FEE
ER
VALUA]—
STORIES 'IYPEC
OCC. GROUP NI
FEE I'LOODZONL
FEESUMMARY
UT EF
SANITARY YN_
RECEIPT g
SCHOOLTAX Y N_
RECEIi
PARK FEE Y N_
RIiCFIVI'M_
BUILDING DIVISION FF,IS
PLANCHECK FEE
GRADING TLE
SOILS ME
ENERGY FEE
PAID
Data Remits
FEE
BUILDING ME
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCDONTAX
PAID
Da.c
PA(0
CWAR 90 1994
CI(Y Ur t Urrnl�L
0