26352 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO - Kffl, n;-ELECTR[CAI. PERMIT NO 6 3 5 2
APPLICATION/PERMIT PLUMBING- MP.CHANICAI. 26352 I{UILIIING DIVISION nr Is' sr.eoo cow" A t srsv 2
. urnr t nn aes
LICENSED CONTRACTOR'S DECLARATION
Dy.L Ihereby affimtlhat l am licensed underpervisionsofChapter9(commencingwith
Ia100 Section 71)00) of Di v':' 3 ofthe Business and Professions Cale, and my license is in
ft., W F full force and eft
�jm Llttnse Class Lle.k
mQy Dale Contractor
~O so,I on er ARCHITECTS DECLARATION
O Z y r shall be useJ lig
F ^ m �
<joe Lima Lesional
OWNER -BUILDER DECLARATION
KOa. V ereby ufllrm that 1 am escorted from the Carburetors License Law for the
u13 ,, bill,, ing reason.(Seetion7031.5, Business and Professions Code: Any city or county
l_�0 ¢ which requires a permit to contact, alter, improve, demolish, or repair any structure
Y� prion,, its issaance,also requires the applicant for such Permit to aligned statement
,,<p that he is l iccosal pnrommto the prov ishmis of the Contractor's License Law (Chapter
d60X 9Unntmencing with Section 7007) of Division 3 of the Business and Professions Code)
to or that he is exempt Overcoat add the basis for the alleged exemption. Any violation of
Section 7031.5 by now, applicant fora permit.mbject. the npplicunuu a civil pcnully of
S nm mum than five hundred dollare(S50O.
a' o ❑ I, as ownemfthepmpeny. carry employees with wages as their sole compensation,
wiudo the work, and thestmetum isnot intended nroffcmJ foraale(Sec. 704,U Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who buildsor improves the ear,and shodeassuch work bimselforthrough his
on employees, provided that such improvements anot intended or offered for sole. if.
hoare wever, Ne building or impmvemcnt is sold within otic year ofeempletion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ [,;is owner oftbe Property, am exclusively contracting with licensedcontractsm to
onsuoct the project (Sec. AW. Business and Proessions CNet) The Contractor's
License Law does not apply to an owner ofpropedy who buildsor improves thereon.and
whomnraets for.uch projects with a cestracm4s) licensed pinamm m the Contractors
License law.
❑ 1 am escmpt undo Sec. , B & P C for this ..an
I WORKMAN COMPENSATION DECLARATION
it ❑ Iherehy alrnn that llmrcacenircate ofconcent to self-insurt,a ucertificate of
Worknv'Compensution lnsur are
r u rlifed copy thereol'(Sm. 3800, Lab C.) which
rs all cm lay a arty m' aA
Policy# r7
Company
❑ Cenirml isherebyfnmided.
Y_Cenified copy is filed with the city insper'tien division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed tribes permit is forone hundred dollars P$100)
or Icor.)
I rectify that in the pie fomarnce of the work for which this permit is issued, I shall
oat employ any {croon in any manner so or, to become subject to the Workers
Datc
z Cnntpcnxmion Luws of California
Applicant
z 0 NOTICE TO APPLICANT :If, after making this Certificate of Exemption, you should
hecame nubjcc ,,,he Workers Commotion.. provisions ofthe Labor Code. you must
> forthwith comply with such provisions or this pcmtit shall be deemed revoked.
W [� CONSTRUCTION LENDING AGENCY
z 1 hereby affirm that them is a construction lending agency for the performance of
O the work her which this permit is issued (Scc. 3097. Civ. C.)
i1. Lender's Nance
OF Leaders Address
U 1 versify tom 1 Love read this application and state that the above information is
c orcl. l agree to comply with all city and county mummers and state laws relating to
building cosnuucrlon,mrd hereby amhodro representatives or Oil city to enter upon the
U Z hove -mentioned property for inspection purposes.
We) agree or save, indemnify and keep hornless the City of Capsicum against
abilit .,judgments, costs and expenses which may in any way accrue against said City
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant state or handle hmandime material
as dcrned by the Cupen inn Municipal Code, Comm 9.12, and the Heath and Safmy
Code. Semen 25.532(.)'1
❑ Yes ❑ No
Will he applicant or future building occupant as, equipment or devices which emit
mountains air concminams as defined by the Bay Arca Air Quality Management
IDis et1
❑ Yea ❑ No
1 have read the hassrdbus materials requirements under Chapter 6.95 of the
California health & Safety Cale, Sections 25505, 25533 and 25534. 1 undemand that
if the building does not currently have a tenant. That it is my responsibility to notify the
cupren of the requirements which must h met prior to issuance of a Certificate of
occupancy.
Ovotr ur uutharivc l oseem Dale
ELECTRIC PERMIT
PERMIT ISSUANCE On
APPLIANCES -R17SIDEYI'IAL
PANELS
UPTO200AMPS
201 - I000 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELECR - SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA,
FIXTURES - PER TRAP
GAS - EA. SYSTEM.I INC. 4 OUTLET.
GAS - EA. SYSTEM OVER 41FA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASE'rRAP
SEWER - SANITARY - STORM IEA. 2000 T.
WATER HEATER WNFNT/LLECTR
WATER SYSTINs TREATING
NEW RESIDENTIAL PLMR, SQ. VC
TOTAL.:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I0,000 CFM)
AIR HANDLING UNIT (OVER I0.000 CPM)
EXHAUST HOOD (W/DUM)
HEATING UNIT (TO 100,000 BTU)
HEATING UNI'[(OVER 100,000 BTU)
VENTILATION IAN (SINGLE R&SID)
BOILER - COMP (3HP OR 100,00i BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENT IAL MECH. SQ. FT.
FEE
FEE
FTE
0
BUILDING PERMIT INFO
BLDG ELECT PLUME MECII
❑ ❑ ❑ J&
ALED I
PU7E
FEE SUMMARY
SANITARY Y N
RECEIPT' N
SCI TOOL TAX Y N
PLANCHI7CK PER
GRADING FEE
SOILS FEE
ENERGY ITEE
PAID
Dill. Reccill#
BUILDING FEE
SEISMIC FEF:
ELECTRIC FEE
PLUMBING Viii
MECHANICAL PER
CONSTRUCTION TAX
PAID
Dam
IWAY 06 1994
Cf1Y Ur t urcn/uuU
ISSUED BY: