26960J IIIIA?���,PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
I4.I BU OF CUPESION ,,,,,, nrL U Bit IN m, eEC MECHANICAL II APPLICATION/PERMIT P."wallG-MRCHANICAs
BUILDING DIVISION
LICENSED CON'TRACTOR'S DECLARATION
OC'Z Ihereby:Rfmnhot l in. liccnsed under pmvisionsofChapter 9(commeaving with
FOO Seelion7") of Divieina 3 of the Business and Profession., Code, and and, license is in
y< full firm. and ribald.
Fy W License Clas �Lic. x
N<N Date Contractor
Z�NZ or
ARCHITECT'S DECLARATION
O Z — 0 1 understand my plans shall be used as public records.
( y L: W]
S�d 2� Licensed Professional
a c'w¢ OWNER -BUILDER DECLARATION
XOaU I hereby affirm that I am exempt from the Contractor's License Law for the
m31_,F„ falmwingreamn. Serino 7031.5, Business and profession, Code: Any cbymcomnty
0; which requires a permit to construct, alter, improve, demolish, or repair any amours,
C�TQ;F prior to its issuance, also returns the applicant for such Permit to file a signed statement
m K M O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
dXo f 9(commencing with Section 700th of Division 3 of the Business and Professions Cot
m—m or that he is exempt therfman middle basis for the alleged exemption. Any violation of
f—Za Section 7031.5 by any applicantfor a permit subjects the applicant to a civil pt,nalty of
ES D not more than five hundred dollen ($5W).
K t—o ❑ do the
work,
the marine is intended
wi offered
for sale
lcompensation,
will duthcwons Cds: swcwniactotin¢ndese Law does not
Business
and Professions but Ids or
pr Contes ractor s License ors such
not apply to an owner is
ownprifeny w employees.
ldsorimphed such improved who am not c tend. himsdfod for sale.
employes.p building
or i Natsuchimprevrmcnthin not ear of
or completion.
ole. If,
however, Ne building r Improvement is that
within one year of complction. thepose of
builder will have the burden of proving Nat he did not build or improve for purpose of
ole).
❑ Las owner of the pmpcny, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Profacsirms Code:) The Contractors
License Law does not apply to an owner ofpropeny who builds or improves thereon, and
who contracts her such laminas with a conwetods) licensed pursuant to the Commator s
License Low.
❑ 1 am exempt under Sec. , B & P C for Nis reason
Qwna Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l have a certificate ofconert to self -insure, or a certificate of
WorkerF Compenamion Insurance ora certified copy durcof(See. 3800, Lab C.) which
rorem all employee's ander this pans&.
ty x
Company
❑ Court copy is hereby furnished.
❑ Ccnifed copy is fled with the city inspection Division.
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is parent, hundred dollars (S Hp)
s Ices)
I cri ify that in the P:Honnance claim work far which this permit is must I shall
not employ any person in any manner so as to become subject to the Workers'
Z Compermationlswsof Cnlifomia. Date
Applicant
O O NOT ICE TO APPLICANT. If. after making Nis Certificate of Exemption, you should
.F rte., &'Come subject to the Worker's Compensation provisions of the Labor Code, you must
tx > fonbwith comply wi tb such provisions or this permit shall he deemed evoked.
0.Q CONSTRUCTION LENDING AGENCY
Z 1 hereby affirm that there is a construction lending agency for Ne performance of
U O the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
OU Lender's Address
I certify that I have mad this application and state that the above information is
F 0.
cement. I agree to comply with all city and county ordinances and state laws relating to
fA building construction. and hereby authorize nlaraenntives of this city to enter uponthe
U Z above-mentioned prnpmny for inspection purposes.
(We) agree to save, indemnify and keep hamJess the City of Cupertino against
Int, , judgments, coats and. proses whieM1 may in any way accrue against said City
I term the Jn/�fy('yr thi,
1m /2n� Zr W r t,
I i atunnf Applicam/Contractor / Date
1 HAZARDOUS MATERIALS DISCLOSURE
W ill the applicant or future building occupant storm or handle havardous material
at Jcf,red by the Cupertino Municipal Cale, Chupter 9.12, and the Health and Safety
Code. Section 25532(a)2
❑ Ycs ❑ No
Will the applicant or future building occupant use equipment ordevices which emit
mardous a4 contaminants as defined by Ne Bay Area Air Quality Management
District?
❑ Vita ❑ No
I have mad the hrtallous materials requirements under Chapter 6.95 of the
California I lealth & Safety Code, Sections 25505.25533 and 25534. 1 undersand Nat
if the building does not currently have a mmmt that it is my responsibility to notify the
cupant of list requirements which must be, mel prior to moral of a CeniOcam of
Dormancy.
Owner or malummd agem Dae
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 201 AMPS
SIGNS ELECTRICAL " L
SPECIAL. CIRCUIT/MISC,
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
PUTLETS - SWI' 1'CHFS-FIXTURES
NEW RESIDENTIALELECIR _SQ. PT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN&VENT- WATERALTER-DRAIN&-WATER(EA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200FT.
WATER HEATER W/VENT/ELECfR
WATER SYSTENtTREATING
NEW RESIDENTIAL PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MCCH,
AIR HANDLING UNIT (TO IB,001) CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCD �1
HEATING UNIT GO 100.000 BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER - COMP (OVER 108,000 BTU)
NEW RESIDENT Ud. MECH. SQ. PT.
BUILDING FEE
SEISMIC FEE
FLE, I RIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
T` /7
.J
Colo?UGf 31'994
FEE
BUILDING PERMIT INFO
BLDG [,LI;q' LB MECI
JOB DESCRIPTION
SQ, FT. FLOOR AREA
S/SQ.
VALUATION
STORIES
TYPECONSTRC
OCC.GROUP
RES. UNIT
FEE
FIOOU_ZONE
APN
FEE SUMMARY
OUTSIDE FEES
SANITARY YN_
RECF.IPI'x
SCHOOLTAX Y N_
RF,CF.IPf x
PARK FEE Y N _
RECEIPTx
BUILDING DIVISIONEIS
PLAN CHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Date Receipt.,
BUILDING FEE
SEISMIC FEE
FLE, I RIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
T` /7
.J
Colo?UGf 31'994
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