26871 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINOU
W LULCa: - LLLt, t Rta:AI,
PERMIT NO.
APPLICATION/PERMIT
PLUMBING - MECHANICAL
ItUIhDING DIVISION
BUILDING PROJEM'ID NTIRCATION
26871
[full.]) �ADURI:
SANITARY NO.
APPLICATIO1NS�UBMMALDATE
V
A,V
LOT#
C� • J
OWNS
PHONE:
ONTR 'S N h E: LIC NO:
N/C
❑
CONTROL. #
rRCHITF.C1'/ENGINEER: LICNO:
ADDRESS:
CONTACT:
PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
Oder Iherebyaf can that l am licensed under provisions of Chapter 9(__.ad., with
¢100 Smnim7000)oi Dlvlslon3ofthe Buslnessond Professions Cod e, end my limnaisin
z V F full force and effect.
<VIn License Class Lie. of
vias Date Contractor
7~Oy- ARCHITECTS DECLARATION
O Z _ ❑ I un lcom nd my plans dill be used as public records.
P,4 L: j
Licensed Professional
�y.Ca OWNER -BUILDER DECLARATION
�'OyU I hereby affirm that I am exempt from the Convectors License Law for the
3LL,Fn following reason. (Section 9031.5. Business and Professions Code: Any city or county
which rcyuircs a permit to cousWq, utter, improve, demolish, or repair any structure
,W}7 prion...
issuance, also requires theapplicant for such pertniuo file. sigreedstammem
5 G p that he is liccoscd pursuant m the provisions of the Comuectors License Law (Chapter
d Kai 9(commencing with Section 7") ofDivision 3offee Businessand Professions Cade)
m—m or that he is exempt herefrom and the hasis for the alleged exemption. Any violation of
FZ,Q Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of
�-E not more than five hundred dollars ($500),
❑ lasowncrofthepropmny,ormyemployxswithwagesm1heirsolecompensation,
a3=° will do the work, and the structure is not intended proffered Bosse (Sm.]tW4, Business
and Professions Coda The Commmur's License Law does not apply to an owner of
property whobuildsor improves thmenuo nd whodoessuchwork himulforthsough his
own employees, provided that such impmvementsare not intended or offered forsale. If,
however, the building or improvement is sold within one yearofcompletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner ufthc property, ran xclusively contracting with licensed contractorsm
construct the project (Sec. TWO, Business and Professions Code:) The Contractors
License Law does not apply IOU mwnerofprorany who builds or improves thereon, and
who contracu forsuch projects with acenuactor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. , B & P C for this return
Owner Date
WORKMAN COMPENSATION DECLARATION
Workers
orkersCompensation
o eeionaInsurance orsicami naed copy
Llab C.) which
rsallemploycssutlnthispermt. f
Policy X
Company
❑ Canned copy is hereby famished.
❑ Certified copy is filed with the city inspersion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not be completed ifthe Permit is fiction, hundred dollars ($lop)
or less.)
1 canary that in the performance of the work for which this permit is issued.) shall
not employ any person in any manner so as to become subject to the Workers'
z Compenestionlawsof California. Date
Applicant
z NOTICE TO APPLICANT:If. after making this Certificate of Exemption, you should
(•-' >
a > forthwith comply wthieth Wsuch Provisions oor
this Permit shall tithe Labor Code, you mon
be decreed revoked.
Gw. O CONSTRUCTION LENDING AGENCY
z 1 hereby affirm that there is t construction lending agency for the performance of
V O tae work for which this permit is issued (Sec. 3097, Civ. C.)
`sn ka'a Nuns
O U Landers Address
1 cenify that 1 have read this application and sore that the above information is
F
bar
construction,
and with alleiry end representatives
of and stat slawsr upon
the
U. Z huildi-menti ructtomert horinsputhrriu rpseentaGvea of this city treater upon the
U z ebov(We).9. property for inspection purposes.
(We) ogres orsave, indemnify and keep harmless the CityCupcnss
em
is,
expenses w ch may in any way accrue against said
sai:d City
to caneWee ofthe grant: Alhis'Pl.a 6�
HAZARDOUS MA'I17RIAM DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the C,amro Munici WI Code, Chapter 9. 12, and the Health and Safety
Cade, Section 25532(d?
❑ Yea ❑ No
Will the applicant or future building occupant use equipment or devices which emit
hazardous air contaminants as defined by the Bay Area Air Quality Management
D'ulrictt
❑ Yes ❑ No
1 have mad the horrendous mmerials nalmo meats under Chapter 6.95 of the
Califamia Hedth & Safety Code S«tions 25505, 25533 and 25534. 1 understand that
if the building does not curarly have a tenant, that it is my responsibility to notify the
occupant mile, requirements which must de met prior to issuance of a Cenifieme of
Owner ar authnnved .,at Date
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2W AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECTR SQ, FT,
BLDG ELECT PLUMB
JOB DESCRIPTION
Foe% zF,J
PLUMBING PERMIT FEE FLoo
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROLE .DEV` \ SANITARY
DRAINS - FLOOR OOF. AREA. CON_.. SCHOOLTAX
FIXTURES PER TRAP PARK FEE
GAS .SYSTEM -1 INC. 4 OL)`SETS _x
- EA.
SEWER- 97A ;A. FT.
WATER 11 EN
WATER SYSTEM EAT[
NEW RESIDENTIAL B. SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT ITO IBOOp CPM)
AIR HANDLING UNIT (OVER I0,1300 CFM)
EXHAUST HOOD(WMUMO
HEATING UNIT (TO 100.00fir BTU)
HEATING UNIT (OVER 100.1100 BTU)
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP CHIP OR 100,000 BTU
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ, FT.
FEE
FEE SUMMARY
n
BUILDING DIVISION FEES
PLANCHECK FEE
GRADING FEE
SOILS FEE
FENERGYFEE
Date Reec le
BUILDING FEE
SEISMIC FEE.
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUM [ON 'rAX
PAID
Date
AUG 15
Clry�r t,urry994
ISSUED BY: - 1�