27369 (2)- USE BALL POINT PEN ONLY
(CITY OF CUPERTINO APPLICATION/PERMIT PLUMBMG MF,CHANICAI. rn 273691
BUILDING DIVISION III NG ING PRO.IECT I[)ENT INICATION
LICENSED
LICENSED CONTRACTOR'S DECLARATION
Matz Iherc itfifirm that l am licensed under provlsiomofCluipter9(commencing with
woo Section ]000) of Division J of the Business and Pmfosions Code, and my license is in
y� full forte and effect.
FZ� License Class Lic.11
mQy Date Convector
Z FOyZ ARCHITECTS DECLARATION
OZ— O I undersand my plans shall he, used as public records.
QNFJ
,1 geJ Licenced Professional
yeegeQ OWNER -BUILDER DECLARATION
KC W, I hereby affirm that I am exempt from the Contmctar's License law for the
W following reason, (Section 9031.5. Business and Professions Code Any city or county
F �-�; which reqirewm an
us a Permit construct, alter, improve, demolish, or repair y structure��}� prior to its issuance. also le9oirts Ne applicant for such permiuo file a signedsammut
K ¢O that he is licensed pursuant o the Provisions of the Commemr s License law (Chapter
X.a a.X 9(commencing with Section ]000)ofDivision 3 offle Business and Pmfessiom Code)
or that he is exemptherefrom and me basis for the alleged exemption. An 14 f
,_Zjg pian, yvioa ono
FZQ Section aw. than
by mydreddantfor apewis subjects the apPlicmuoecivil paternity of
SCO nm more owu five hundred dollars(Sem).
as atm ❑ do fou
thenrufflae somny,ormycmtended witheres ant forsheirsoole .7044, runion,
2i— will dothewons ander he Comiinor'sLicese Laoffereddoes not
to wo Business
and Professions Code: pr Contractor's 11he mr's License Law Jaen not apply tort owner of
ownenywhob. buildsorimproves thereon, and whodaes such work himselfedthrough his
employees,pmvidWmpr such impmvemwthin not ewofcJoroecrtd Thede.IL
however,thebuilding or den of improvement is hath within one year or completion, t purpose
r-
ble.). will have the burden of proving that be did not build or improve for putposwf
ale.).
❑ Iuel owners(mc PropSec. 70,14. Business and Prraming unis Cith licen'M contractors to
conLicense
et the project (Sec. in
ncrol s and ywhol mid Gxmprove Contractor's
Licenm Luwdocs such
apply to on owncovaracrperty wFo sed puns ant to
theoeContractor's License raw. for such pmjeeu with aeonuucmr(s)Ikensed DursuuntmIM1e Cnnaaemr'e
Ekes¢ Lew.
❑ 1 em exempt under gee. . 11 & 1' C fur this rcaaon
Owner Date
WORKMAN COM P17NSATION DECLARA'I UM
❑ Iherehy affirm mm lhavcucertilicalc of ttmsnt er self -insure, orncertiRcutc of
Workers' Employee a n Ire this p ora cenlOeJ copy merrof (Sec. JX(Nk Lub C.1 whjeM,
rs all employee under this pewit.
_ PolicyN
Company
❑ Cenifedcupyishcrebyfumished.
❑ Certified copy is fled with me city inspection division
CERTIFICATE OF EXEMPI'I OM WORKERS'
COMPFNSATIO NSURANCE
(Thkov,donnceJnotbecompletedi the,mantxfmonehumbeddollan (SI 1
or tossed
lemifyflisamtheperformanceofth workforwhich mix permit ix is d I. 1
not employ, any person in any manner s as to hccnme sub' t to ers'
z Compewtionlawsof Califomia. Date e
Applicant
z NOTICE'TO APPLICANT:If.ahermaking lhi Ti0cute of Ea n,ywshould.
F(/] becomesubjs"B'the Workers Compensation Dm isinns x(111 bar "mamLLst
? foMwith comply wird such provisions or This Ix shall be deemM v kW.
d Q C(NSTRUCf10N LENDING ENCY
Z I hereby affirm That shcm is a conswctinn lending ency for she performance of
U C) the work for which this pewit is issued ISa. 309), Civ. )
I endo, Name
0I" Lenders Address
V 1 certify that l have read his
applintion and sum roar a above infortnedon i
} correct. IagrecwcmdPlywilhallcilyvr `Ci.mIy ordinances sate laws relaxin
E" ran' building conswedun, and hereby uumoriu rtpresenusivesof mi, ilymenmru she
U Z above-memimod Property for inspersion DuOnses.
(We) agree to save, indemnify and keep hawlcss rhe City o ape no against
liabilires.judgments, coxa and expenses which may in any way novice against said City
Sigatm of ApplicaogC9dmacmr Vane
11 HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building nixupont store of handle hazmdom material
aet defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety
Code. Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupvm use equipment or devices which emit
hazardous air commitments as defined by the Boy Area Air Quality Mmogemem
District?
❑ Yes ❑ No
1 have read rhe Inaurdoux materials re,mmuams under Chapter 495 of me
Cal romiu I Icahh & Safety Cale, Sections 25,105, 25533 and 25534. 1 undersand that
if the building does not currcnJy basteamnanl, ibm it ix my ¢eponniWay I notifythe
a:cupnm of the scinuo,ovents which most he nmi prior to issuance of u Certificate of
acapanry.
Owner or omhmizcJ agent Date
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENUAL
PANELS
UP TO 200 AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIALCMCUIT/MISC.
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
AurrR - DRAIN & VENT- WATER (EA)
RACK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
FIXTURES- PER'rRAP
GAS - EA. SYSTEM -1 INC 4 OUTLETS
GAS- A. SYSTEM-OVER4(EA)
GREASFJ DUSTRL WASTE INTERCEPTOR
- STORM EA. 200FT
SQ, PT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO Ur" CFM)
AIR HANDLING UNIT (OVER 10.011) CFM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER Im,mO BTU)
VENTILATION PAN (SINGLE RESID)
BOILER -COMP LIHP OR 100.000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
FEE
FEE
IN]
❑ J ❑
10 Fyn SCBIPf10N
SQ. FT. FLOOR AREA SNQ. FT.
PETE SUMMARY
SANITARY Y N
RIiCRIPI' b
SCI{001. TAX YN
PLANCHECK EEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Dae HecciptM
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
FEE PLUMBING FEF,
MECHANICAL. FEE
CONSTRUCTION TAX
PAID
Dutc Rcccipi p
1 renal
FEB 81995
CI I Y Vr, L, urcri I five
59
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