28254APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -
CI7'Y OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION (—
LICENSED CONTRACTOR'S DECLARATION
1 hereby atlfre that I am licensed under provisions of Chapter 9(commencing with
Section 700f) of Division 3 of the Business and Profexsiors Code, and my license is is
full five and effiml
Live E142 uc. # C,
Dale? Commctur asr- X�lper
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
Licensed professional
OWNER -BUILDER DECLARA'BON
I hereby affirm that I am exempt from the Contractor's License law for the
following reason. (Section 7U3 L5. Business and Prolesslons Code: Any city or county
which requirm a permit in a...ma,, aIle. improve, demolish, or repair any $vadum
prion its issuance also requires the npplicanl forsuch penmiuo file a signedstatement
that he is licensed pursuant to the provision,of the Contractor's License Law (Chapter
9 (commencing with Section 7000) of Division 3 orthe Business and Professions Code)
nr thot he is exempuhcrefrom and the breis for the allege) exemption. Any violation of
Semon 703 LS by any applicnm for a permit wbjecu IM1e applicant to a civil penalty of
nor tome than five hundred dollars (M).
❑ Las owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure isnot intended or offered for sale (Sm. 7044, Business
and Pmlessions Castle: 11c Conlmctors License Law does not apply In an owner of
property who builds or improves thereon, and who docs such work himself or through his
own employms. provided that srac h i mprovemamu are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of IM1e progeny, am exclusively contracting with licensed conlmnu¢]o
mmon the project (Sec. 7041. Business and Rofaxions Code I The Contmemh
License law does not apply to an owncrofpropcny who builds or improves therenn.and
who contracts forsuch projects with a contmaor(a) licensed pursuant to the Convector's
Livsnse law.
❑ 1 ant exempt under Sec , B & P C for this mason
Owner Date
WORKMAN COMPENSATION DECLARATION
,Del hereby affirm that 1 have a mati ftcate of consent to w1f.imure, or a certificate of
WorkersCompcn.¢uien Insurance or acerb tied copy thereof (Sec. 3800, Lab C.) which
Policy# TTA-TIUA) 10.5
Company
❑ Cradled copy is hereby with the city
❑ Ccnifml copy is Olad with the city inspersion division.
CER' I'1171CA'rE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(This section need not be completed if the permit is forone hundred dollars ($ IM)
or Icns.)
1 artily that in the performance of the walk for which this Permit is issued, I shall
not employ any person in any insurer w us ,, become ,.hjcct ,, the Workers'
ZCint"nsatoioLaweof Califomia. Date
Applicant
Z0 NO[ ICE TO APPLICANT': Barter making this Cenificate of Exemption, you should
(~ become subject to the Workers Compensation provisions of the labor Code, you must
a > forthwith comply with such prov.... mor TMs pemrit shall be deemed revoked.
CONSTRUCTION [.ENDING AGENCY
A I herchy affirm that them isa construction lending agency for the performance of
V U the work for which this permit is issued (See 3NO. Civ. C.)
Leadeh Name
U., H Lender's Address
0 U 1 minify that I have read this application and sure that the above information ii�
correct. I agree it) comply with all city andumnty ordinances and.vare laws relitirtm
f-' [Z) building conswetiuv, unit hereby authorize representatives of this city toa Ando
UZ ee above-mentioned property for inspection purposes.
(We) agrto nave, indemnify and keep harmless the City of Cupe sagaiost
I ✓
I IAZARDOUS MA'I ERIALS DISCLOSURE `'
Will the applicant or future building acupant store or handle loiardems manor
as defined by the Cupoman Municipal Code, Chapter 9.12, and the I lcalth and Safety
Code, Start— 25532(.)7
❑ Yes ❑ No
Will theapplicaut or future building occupanme[equipment ordevices which emit
harardous air con ornments as definW by the Bay Area Air Quality Man ,taneat
Donnat'7
❑ Yes ❑ No
I bar, read the hteardous materials requirements under Chapter 695 of the
Califomia Ifealth is Safety Code Sections 25505.25533 and 25534. 1 understand that
il'the building does not currently have it tenant, that it is my responsibility to notify the
occupant of the requimreents which must be met prior to issuance of a Comficale of
Ocrupaney.
Owner or sunburned agent Dam
PLUMBING
NAME:
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENT IAL
PANELS
UP TO 2M AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUFUMISC.
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RPSIDEMIAL CLEM _SO. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALPER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOT, AREA, COND.
FIXTURES - PER TRAP
GAS - IA. SYSTEM -1 INC. 4 CIA LETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY -STORM EA. 300FT.
WATER HH,VlER WfVHN'1'II?I.ECIR
WATERSYSTEM/IREATING
NEW RESIDENTIAL PI -MB. SQ. Er.
Q V TOTAL:
PERMIT
NA�J71 NRG UNIT (To lr.mfo CFM)
HANDLING UNIT(OVER I0.0100 CIM)
EXI IAUST'HOOD ( W/DUC7U
!(EATING UNIT (TO IW NK BTU)
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP LINE OR IIXLWO BTU)
BOILER . COMP (OVER I W W0 BTU)
NEW RESIDENTIAL MECIL SQ. FI'.
FEE FLOOD ZI
SANITARY
SCHOOL
PARK FEE
BU
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Dam
FEE
FEE SUMMARY
BUILDING FEE
SEISMIC FEE
ELF,CfRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Date
Y N
REC121K #
Y N
Receipt #
TOTAL:
P,4
Qry ut- f 2 � 1995
EkIInI�j
ISSUED BY:
^
PERMIT NO. 28254
TUN
SANITARY
NO.
APPLICATION SUBMITTAL DATE
LIC NO:
9S
NIC
❑
CONTROL#
1
FEE
BUILDING PERMITINFO
RLDG
❑
ELECT PLUMB MECH
❑ E]TOB
ISCRIFDON
SO, FI'. FLOOR AREA I S/SO. Fr.
SIGNS ELECTRICAL
SPECIAL CIRCUFUMISC.
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RPSIDEMIAL CLEM _SO. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALPER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOT, AREA, COND.
FIXTURES - PER TRAP
GAS - IA. SYSTEM -1 INC. 4 CIA LETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY -STORM EA. 300FT.
WATER HH,VlER WfVHN'1'II?I.ECIR
WATERSYSTEM/IREATING
NEW RESIDENTIAL PI -MB. SQ. Er.
Q V TOTAL:
PERMIT
NA�J71 NRG UNIT (To lr.mfo CFM)
HANDLING UNIT(OVER I0.0100 CIM)
EXI IAUST'HOOD ( W/DUC7U
!(EATING UNIT (TO IW NK BTU)
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP LINE OR IIXLWO BTU)
BOILER . COMP (OVER I W W0 BTU)
NEW RESIDENTIAL MECIL SQ. FI'.
FEE FLOOD ZI
SANITARY
SCHOOL
PARK FEE
BU
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Dam
FEE
FEE SUMMARY
BUILDING FEE
SEISMIC FEE
ELF,CfRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTIONTAX
PAID
Date
Y N
REC121K #
Y N
Receipt #
TOTAL:
P,4
Qry ut- f 2 � 1995
EkIInI�j
ISSUED BY: