19961APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
7—
affirm
affirm that I am Ikmaed under
Ilave l.In full fore ad effM.
Idmve Class Lk:.I
nate coMrid.,
ARCHITECTS DECLARATION
I underwaad my plant shall be used as public Cuda
Llocnted Prefesbvl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cordrenor'• Llarue Law for the
owing reaBon. (Seaton 70115, Buer. arta Prof elov Code: My tlty or
file • signed latement that he at Braved pursuant to the pmviebm of the
Contractor's Lberue Law (Chapter 9(mmmenMg with Se Ilan 9W0) of Di 4
alon 3 of the Bulnee and Pnufeabv Cade) or that he b exempt therefrom and
the lista for the alleged exemption. Any violation of Section 7MIS by any
.ppBant fora permit subieee the app".t to • dvil penalty of not more tion
flvthI,undred dollars (S M.
u . owner of the property, or my empbym with wage as their sole
osrnpevadce, wlBdothe work and thelvaua b not intended or offend for
ale Su, 70µ Buetnea and Pruferbv Cade: The CoMraaora Llama law
does not apply to an owner of property who builds or impmr as thereon, ard
who dm ash work hlmaelf mthrtegh hie own employees, prwtded that such
impownreob as not Intended or offered fee Bale. If, howas r, the bulidingor
Improvement bsold within one yea rofcompletbn, the owner-bulW erwill have
Xt rden of provfng that he did not build or Unprove for put rpose of Bele.).
L a owner of the property, em cel aively oantrading with Named
IXon in covtva the projet(Se, 70M Brims and Pmfrubm Code:
The Contractor'. Lirenm Law don not apply to an owner of property who
Wild. or Improve thereon, and who roMrarts for aueh projects with
cgn4v�1turw Bormed pursuant to the Cantractal. Llan. Law.
LJ I am eamp under Be. JB 6 P C for thio aamn
❑I hereby •f@m that I have a
eerORrateof Worken'Cwnpematlo
3800, lab Q
Co�mparay
I I CenNed ropy b hereby fumlehed.
LF`Ji Cerifird copy Is filed with the city Inspection dlvWon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Lids section need not be completed if the peradt b ferone hundred dollars
Rt 00) or ler3
I certify that in the perfomina of the work for which this permit Is bred,
1 shall not employ any pennon In any runner so as to become snbjeet to the
W«kerx'Compi,.timn Lwsof GBfomla. Date
AppBcent
NOTICE TO APPLICANT: 11, after making thla Certifiate of Exemptio , you
should become subject to the Workers' Comp<vatbn provisions of the Labor
Code, you must forthwith comply with such Imwisbm or thio permit shall be,
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that thea b • coretvaglon lendinagency for the perform
as of the work forwhkh this permit Is Issued (Sec. 3097, CW. Q
Leader. Name
lender's Addrva
1 mrtify the] have rad thbappllratbn and steethatthe above Information
h correct. I agree I. rnmply with all dty and county onBnancce and late laws
relating to binding mmtvctlon, and hereby authorlm mpneenutW ofthio
tlty to enter upon the abwo-mentbned Property for Wpe lcm purpoaaa.
(Wr) agree to save, indemnify an it keep harrrJ m the City of Cupertiro
against IlabWtka, jodgments, oora and expeva which may in any way a.
Aga Wt said City b c..aque of thegnmbg p t
this perm.
?"F/Wfl �4jf a %m-4%9 1<�
Signature of AppBrant/Cbmrmterjf�v (—e pal--P---
HAZARDOUS MATERIALS DISCLOSURE
Will the appIrmnt or future buBding ocropet store or handle h.vNous
material a defired by ted C.Pedi. MuNdpa)Cade, Chapter 9.12, ad the
He❑alth anSafety CodeJL—SJ�eason 25532(a)i
WYn u�
Blthe appBant« cure building oacvpatux equiprrcnt or devim
which emit harandoue air contaminant... defined by the Bay Arca Air
QueIR Mavgemend Dbtruct2
11e, ��
haveradt Health& mte ode,Se rnrybemcnb5533 aChapter .1 of
the Calffo t tifthkSafety Code,S mm25505,25.tandt,th.t ]
andeMandthat notify
theocc dont not a rrcntly loves tenant, runt b fs nary
rapovBaaoe to of. cthe occupant of the requirements which nasi be rret
prior to lauana of a CeNBvb of Omrpanry.
Owner« autharbcd agent . Data
CITY OF CUPERTINaBUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTRICAL IMUMBINGMFLFUN)CAL
ELECTRIC PERMIT
ELECTRICAL
METER OR POLE INST.
n;gLfrx�
NG IDOL ELECTRIC
ALTER -DRAW A: VENT- WATER (SA)
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, ARP-, COND.
FIXTURES PER TRAP
GAS FA. SYSTEM -1 INC4 OUTLETS
CAS EA. SYSTEM-0VER 4 (EA)
CREASE/INDUSIRL WASTE INTERCEPTOR
CREASE TRAP
SEWER -SANITARY -STORM EA 20 FT.
WATER HEATER W/VENT/EIEC7R
WAT IRSYSTEN/TREATING
NEW RESIDENTIAL PLMB. SQFT.
TOTAL
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNTT (OVER 10,000 CTNO
EXHAUST HOOD (W/ DUCT)
HEATING UNIT (TO 100,000 BTU)
HFATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOdFRCOMP OHPOR IW,RD BTU)
BOILER-COMP(OVER 100,000 BM.
OFFICE COPY
FEE
FEE
FEE
I'IXhIT NO.
19961
APPLICATION SUBM=
ecy
CAIT;ORY
CONTROL
BUILDING PERMIT INFO
❑ ❑ ❑
JOB DESCRIPTION
PLF_x
D SQ. r�R AREA
TER
$/SQ. FT.
s
VALUATION
STORIES
TYPE CONSTRUCTION
VV
OCC.GROUP
2-3
RIS UNITS
FLOOD ZONE
APN
FEE SUMMARY
QUTqIDFFFVq
SANITARY Y_ N
RECEIPT N
SCHOOL TAX Y_ N
RECEIPT N
PARK FEE Y_ N
RIZ Env W-
-BUILDING DIVISION FF. CS
PLANCHECK FEE
PAID
Date Rani t#
ENERGYFFE Y ' N
PAID
Date Recti t#
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#
SUBTOTAL
CONSTRUCFIONTAX a
CONSTRUCTION TAX PAID:
Date Revel t#
TOTAL:
ISSUANCEAATE
01��J
'City cf CIlo�rtino
ISSUED BY: WE -7 1 --Na I:A