25698 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING ,ELL R AI.
CITY OF CUPEAPPLICATION/PERMIT ICATION/PERMIT PLUMBING - MECHANICAL
BUILDING SSVISIONNO DIVISION BUILDING PROJECT IDENIIFICA
BUILDING ADDRESS:
XPri< 14-vct _ \ v�% C PKA- cif roti.,.
LICENSED CONTRACTOR'S DECLARATION
Matz Ihercbyaffirmthm l am license under provisionsofCTaptef9(commenon, with
F100 SectionWar)) of Division 3 of the Business and Processions Code, and my license is in
Cat full force and effect.
=Z•y liverva, Class Lice
Qi Date Contractor
ZOyz ARCH[rECTS DECLARATION
O z — ❑ I understand my plans shall be used as public accords.
m
ZY�„,j Licensed Prnfcusional
KO�< OWNER -BUILDER DECLARATION
W U I hereby affirm that I am exempt from the Contractors License Use for the
W 3ta., following reaeon.(Scetian7031.5, Business and Professions CMc: Any city or county
t' it Om; which arms ires a permit to construct. alter, improve, demolish, or repair any structure
Y$ prior to its issuance. also requires the applicant COT such permit to rile a signed statement
iW Cp,<0 that he is licensed pursuant to the Provisions of the Contractors License Law (Chapter
X� 9(commencing with Section 7000) of Division 3 of the Business and Professions Code)
W _rn or he is exempt hembom and the basis for the alleged exemption. Any violation of
FZ� Section 7031.5 by any applicant for a permit subjects the applicant to a civil pewlty of
ESM¢
not mom than live hundred dollars (S500).
tCts, ❑ 1, as owner oftho property, or my employees with wages as thalrsele compensation,
a3— will du the work, and the structure, is not intended or offered for sale (Sec. 7W, Business
and Professions Code: The Contractors License Law does not apply to an owner of
propery who builds or improves themon, and who dens 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 ofemopletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
We.).
❑ Las owner of the property, amexcluslvely contracting with licensed contmcmrs to
removal the project (Sec. 7044, Business and Professions Code) The Conuachera
License law does not apply to an owner ofpmpeny who builds w improves thereon,and
who comrade forsuch projects with a conu:atof(s) licensed pursuant to the Conuacmr.s
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Data
WORKMAN COMPENSATION DECLARATION
covers�❑ I hereby affirm that l have a emaewm cleanse, to.seleinsuro, ora cenificzm of
nr
Workers Compensation Insurance certified copythercof(Sec. 3800J.ab C.)which
all employee's under this Marten.
Policy #
Company
❑ CeniOal copy is hereby furnished.
❑ Candied copy is filed with be city irespcchma division.
CERTIFICATE OF EXEMPTION MOM WORKERY
COMPI?NSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars 15100)
or Ices.)
I certify that in the performance of the work for which this permiris issued, l shall
not employ any person in any maturer so as m become subject to the Workers'
z Compensationlawsuf Calificari Data
Applicant
z 0 NOTICE I'O APPLICANT: If, after making this Certificate of Exemption, you should
r(A become subject to the Worker's Campensauon provisions of the Labor Code, you must
a 7 forthwith comply with such provisions or this permit shall adeemed revoked.
p, A CONSTRUCTION LENDING AGENCY
z 1 hereby affirm that hem is a concoction lending agency for the perfornarrce of
J O the work for which this permit is issued (Sec. 3097, Civ. C.)
Leaders Name
Q U Lender's Address
I certify that I have read this application and state that the above information is
Fa c erten. l agree to Comply with all city and county ordinances and state laws relating to
buil' cmstruction, and hereby announce representatives of this city to enter upon the
U z ere -me Toned progeny fof mareatma purposes.
(We rem 10 save, indemnify and keep harmless the City of Cupertino against
liubilir. osis and rewry'ch may in any way accrue agr.,ii ity
Inc se n. etWtlrn� of,FF/l
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Carle, Chapter 9.12, and the Health and Safety
Cale, Section 25532(1)?
❑ Yes ❑ No
Will the applicant orf umre building occupant use equipment or devices which emit
himardous air contaminants as defined by the Bay Arta Air Quality Management
District?
❑ Yes ❑ No
I have Tend the harefdous materials requiremems under Chapter 6.95 of the
California Health & Salary Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a ream, that it is my responsibility m notify the
cupont of the requirements which must be met priman, issuance Of a Cenifi<ate of
Occupancy.
Owner or authorized agent Dare
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMP i
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEcTR _SQ. IT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - GRAIN & VENT - WATER IPA)
BACK FLOW PROTECT, DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS -IIA. SYSTEM -OVER 4 (EA)
GREASEnNDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER BEATER W/VENT/ELECTR
PLMB. SQ, IT.
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECI1.
AIR HANDLING UNIT(TO IO,OW CPM)
AIR HANDLING UNIT (OVER 10AOo CFM)
EXHAUST HOOD(W(DUCf)
HEATING UNIT (TO IDTWO BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100.000 BTU)
BOILER - COMP (OVER I00,000 BTU)
NEW RESIDENTIAL MECI. SQ. Fr.
FEE
• • i
BLDG ELI❑: PLUMB ME❑CfiOr
LE® IN
PUTER
FEE
FLOOD ZONE
FEE SUMMARY
OOI', IDEFEES
SANITARY
Y I
RECEIPT#_
SCHOOL. TAX
Y 1
RECEIPT#_
PARK FEE
Y I
RHCEIPI' p _
BUILDING DIVISION FE
PLANCHECK FEE
GRADING FEE
'
SOILS FEE
ENERGY FEE
PAID
Data
Receipt#
TOTAL:
FEE
BUILDING FEF.
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECI IANICAL FEE
CONSTRUCIONTAX
PAID
Data
PAID
NOV -1 1993
CO Ur Guethlisu i