24603 (2)CITY OF CUPERTINO "" 1—no, ""
BUILDING DIVISION APPLICATION/PERMIT " PLUMBING
MECHANICAL ,ru g9 d R n _,i
PHONE:
410ENSED CONTRACTOR'S DECLARATION
0Cz I hereby affirm that l son licensed under previsions of Chapter 9(commencing with
0.100❑ Sect1an7000 o rvbto 3ofthe Business. dPro n C e, and my license is in
Fy-6zF fulltome and fe 0
6z 5W License Clas) �/ oCom
rnQy Dam
Fye ARCHITECTS DEC A 10
z`o 1 understand my plans shall be used us public records.
.....]I Licensed Frnfession.l
�a OWNER -BUILDER DECLARATION
OaU 1 hereby affirm fast 1 mm exempt from the Contactor'. License taw for the
3
on following reason. (Section 7031.5, Business and Professions Code: Any city or county
y which requires a permit to construct, alter, improve, demolish, or repair any structure
Wei
prior to itsissuance, else requires the applicant for such Permit o file a signed statement
6 Q0 that he is licensed pursuant to the Provisions of the Comractor's License Law (Chapter
0.0 9(commencing with Section 7")of Division 3 of the Business and Professions Code)
XW _y or that he is emm,adicafrom it the basis far the alleged exemption. Any violilum of
F Z G Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
Cnet more than five hundred dollars ($500).
W m ❑ 1,nowneroflhepr.pery,ormyemploymswilhwagnastheirsolecompn 6m,
a willdo the work,andlbe sractumitnol intendWoroffered formic (Sm. 7W, Business
and Professions Code: The Conteacha s License Low does not apply to on owner of
property who builds or improves themon, and who dee. such work himself or through his
own employees, provided that such improvements arc not intended or offered for sale. If,
however, the building or improvement is sold within one year of ompletion,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,nrallies property, am exclusively contracting with licensed contactors to
construct the pmjmt Sm. 70ub4, Business and Professions Cade:) The Contmcmh
License Lawdorsnal apraymserith eco (property whobuildsorimproves thefeon,sed
who com Law. for such projecta with acontacmr(s) licensed pursuant. the Contrvetors
License Law.
❑ 1 ore exempt under Sec. , H & P C firt this an.
Dw er Dat
WORKMAN COMPENSATION DECLARATIONffi
I hereby arris that 1 have a manifcam of consent m self -home, or. cenilicsm of
kers'Computration lnsumape Sae cgBffirun9¢y,gereof(Fec. 3800, Lab C.) which
Policy # Vv Vg a�w+� a a�
Comps y
❑ C��rrttifed copy is he byith tum city
�#¢enifed copy is filed with Ne city inxpecti.n division.
�� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
phis sectionneed nor becompleled ifthepemdl is formoloo loot dollars ($100)
orless.)
1 cenify that in the performance of the work forwhich this permit is issued, I Nall
not employ any Person any manner so as to become subject in the Workers'
z Compensation Lawsof C.1ifomia. Date
Applicant
O 2 NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
f� DO become subject 1. the Workers Compensation provisions of the Labor Code, you muss
a ^ forthwith comply with such provisions or this pentyl shall be decreed revoked.
Lit G CONSTRUCTION LENDING AGENCY
z I hereby affirm that there is a continued.. lending agency for the performance of
Othe work for which this permit is issued (Sec. 3097. Civ. C.)
Ll.landers Name
Lender's Address
iU 1 cenify that 1 have mad this application and slate that Ne above informm en is
correct. I agree to comply with all city and county ordinances and stale laws relating to
hh building construction, and hereby autharice representatives afthis city to enter upon the
U z muse -mentioned property for inspection purposes.
(We) ogres to save, indemnify and keep hemJess the City of Cupertino against
IiabilitieyajudglT nts,cots madfrismates, which mayjn any way saxame against said City
Will the applicant or future building occupant.mrc or handle hazardous material
n defined by the Cupertino Municipal Code, Chaptr 9.12, it the Health and Safety
Code, Section 25532(x)?
❑ Yes ❑ No
Will the applicant m future buildingmcupantuee uipmentordoviceswhichemit
hoaurdous an conterminous as defined by the Bay Area Air Quality Management
District?
1 ❑ Yes ❑ No
I have read the himardous materials requirements under Chapter 6.95 of the
C.lifomiu Health & SafetyCode. Sec6an 25505, 25533 and 25534. f understand that
ifrhebuildingdoesnor havealactam .haulms my responsibility tnotify N
occupant of the rcyuircmentsenu which must M mer prior to issuance of a Certifiwe of
Occupancy.
Owner or aathodud agent Dae
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2M AMPS
OVER 1000 AMPS
77 ®
�.+'f
I N
L II{•�l
ALU,
-Z�
3
TEMP. METER OR POLE INST.
'
N/C
OUTLETS - SWITCHES - FIXTURES --
CONTROL#
NF.WRESIDENTIALELECTR_SQ. FT.
FEE
BUILDING PERMIT INFO
BLDG
1:1
ELECT PLUMB MEECH
1:1 1:1X
OVER 1000 AMPS
77 ®
�.+'f
I N
L II{•�l
ALU,
SIGNS ELECTRICAL
___771=77,D
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES ' -
SWIMMING POOL. ELECTRIC 'I'
OUTLETS - SWITCHES - FIXTURES --
NF.WRESIDENTIALELECTR_SQ. FT.
STORIES
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (HA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - II. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER HEATER WIVEN'OHLECTR
WATER SYSTEM/IRGATING
NEW RESIDENTIAL Pi SQ. PT.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR I IANDLING UNIT (TO I0," CFM)
AIR HANDLING UNIT (OVER 10,00) CFM)
EXI IAUST HOOD W(DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I W,M BTU)
VENTILATION FAN (SINGLE RESID)
BOILER- COMP QHP OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
OFFICE
TOTAL:
FEE
FEE SUMMARY
PARK FEE Y _N_
RECEIPT#
BUILDING DIVISION FEES
PLANCHECK FEE
GRADING FEE
SOILS FEF:
ENERGY FEE
PAID
Date Reccipt#
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC ME
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dula
PAID
AUG - 21993
CITY OF cuto unU