25821 (2)rY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
"A,
LICENSED CONTRACTOR'S DECLARATION
pyiZ l hereby affirm that l am licensed under provisions of Chapter 9(commeneing with
Poo Section 70Wes
) of Division 3 of the Busins and Profusions Code, and my he.. is in
^'uUIna farce and effect. 1
Q<Z W Liwnse Class Liu N
m Q ti DoleContractor
z0.K-ARCHITECTS DECLARATION
O Z O 1 understand my plans shall be used as public records.
�_—
Licrnred professional
OWNER -BUILDER DECLARATION
O a F I hereby affirm that 1 am exempt from the Contractors License Lew for the
W 3 W mfollowing accord. (Section 7031.5, Business and Professions Cade: Any city or county
(_ � oo a which requires a permit in construct, alter, improve, demolish, or repair any structure
WQ� prior,. as issuance,an
lso blimame applicant fmxuch penniuo file. signed sustained
4 O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9(commrming with Section 7000) of Division 3 of the Business and Professions Cade)
^Jy
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
�Z} Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
M� � O t re than five hundred dollars
m as wnerofthe property. army employees with wages u their sole compensation.
y ill owork, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Cade: The Contmcmrs License Law Juts not apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
own employees, Provided that such improvements arenot intended creffesed for sale. If,
however, the building orImprovement is sold within one year ofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
ml,).
❑ I, as owner of the property, am exclusively contracting with licensed contractors an QI
construct the project (Sec. 7014, Business and Professions Code:) The Contractors
License Lawdoes not apply ct m ownerof property lihose lids siimprovu Courac and
whonse Lace for such projects with a comnctoKs) licensed pursuant m the Conwnoh
License Law.
❑ 1 um exempt antler Sec. , B & P C for this mason
Owner Dore
WORKMAN COMPENSATION DECLARATION
[3 I hereby affirm that l have a certifican ofconmm to self-insuce, at a conlflcare of
cWovemal l Ceommpploeynesea'tis ounder this ems versified copy therwf (Sec.3g00, lab CJ which
permit.
Policy M
Company
❑ Certified copy is hereby furnished.
❑ Certified] copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section iced not be completed ifil epemtit is for one hundred dollen EI HRE
or less.)
I vainly that in to po-fin ence of the mark for which this permit is ismed. Ishall
not employ any person in any masmer a. as to become subject to the Workers
z Compensarion Lawsof Califamia, Date
Applicant
z NOTICE TO APPLICANT: If, after making this Condition of Exemption, you should
�r` bccomen conald, it Workers Campensetis formal omoftheanced Cody you must
, forthwith comply with such provisions or this pemdt shall be rimmed invoked.
CONSTRUCTION LENDING AGENCY
Vz I hereby affirm that then is it construction leading agency far the perfosmmce of
O the work for which this permit is issued (Ser. 3097, Civ. C.)
Lenders Name
O U Lenders Address QT
1 certify Nat I have read this application and state that the above informed. is
rY" PW. correct I agree to comply with all city and county ordinances and sure laws missing to
f'^ U) building construction, and hereby suNmin repreventativu of this city to enter upon the
U z above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap hmmless th f in
liabilities,judgmrnn�cosm andexpensuwhich mp' any ey eves d n
I. conxquence olgiu(iundust Qr4Wylft / in
HAZARDOUS MATERIALS DISCLOSURE
W01 Ne applicant at future building occupent stop or handle hazardous mensual
as defined by the Cupertino Municipal Code, Chepnr 9.12, and the Health and Safety
Code. Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which emit
limitations air commandments as defined] by the Boy Arra Air Quality Management
Distrct?
❑ Yes ❑ No
1 have read the hamrdom materials requirements under Chapter 6.95 of the
Celifomio Hevth & SafetyCade, Suharto 25505.25533 end 25534. I misho m ul thin
if the building does not currently have a must
m, that it is my insane of a o notify Ne
occupied of Ne requinmenn which must be met prior m issuance of a Cenificaa of
Occupancy.
Owner or manodred agent Dan
PLUMBING - MECHANICAL
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEWRPSIDENTIALELECPR _SQ.FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (FA)
BACK FLAW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4(EA)
GREASFF7INDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM IiA. 200FT,
WATER HEATER WNENT/RLECIT
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ, FT.
TOTAL:
MECI IANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT(OVER 10,000 CFM)
HEATING UNIT (TO IM." BTU)
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 108,000 RTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RMIDENIALMECH. SQ.FT.
N
ATP
FEE FLOOD ZONE.
FEESUMMARY
FEE
PLANCHECK nils
GRADING FEE
SOILS IEE
ENERGY IEE
PAID
Data Receipd0
TOTAL:
BUILDING FFR
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dore
fayr
04-0.6
. �lTy �r 1993
(�bbr�nllly�
.. ✓ ��
ISSUED BY:
25821
_
SAN TEARY NO.
APPLICATION SUBM I IT' N. DATE
O:
NIC
CON'1'ROLp
FEE
BUILDING PERMIT INFO
ELECT BLDG EPLU❑MR ME❑CI{
ELECT
�.
N
ATP
FEE FLOOD ZONE.
FEESUMMARY
FEE
PLANCHECK nils
GRADING FEE
SOILS IEE
ENERGY IEE
PAID
Data Receipd0
TOTAL:
BUILDING FFR
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Dore
fayr
04-0.6
. �lTy �r 1993
(�bbr�nllly�
.. ✓ ��
ISSUED BY: