26951BUILDING urvlsloN v APPLICATION/PERMIT
LICENSED CONTRACTOR'S DECLARATION
q.Z I hereby affirm that lmr licensed under provisions of Chap'er9(commencing with
00 Section 7000) or Division 3 of the Biamcss and Professions Code, and my license is in
,,UUfullforce and eft
HZW License Class _ ic.# C'l
V)QIt.y Date Contractor.
ZOyZ ARCHITECTS DECLARATION
0Z_ ® I understand my plans shall be ..itas public records.
9qF y �.'...I1I LicensedProfessional
gY7 OWNI;R-BUILDER DECLARA9'ION
iyax(OaF I hereby affirm that I and exempt from the Contractor's Idemse Law for the
W 3 ta H following reassm. (Section 7031.5, Business and Profession Code: Any city or county
❑e which mquirex a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
W C O that he is licensed pursuant to the Provisions of the Commemrs Licam a Inw (Chapter
a e� 9(commencing with Section](X10) of Division 3 ofthe Boammurnl Professions Cade)
Smith 101 Elbymherefmmand the Permitortheas egedexempt, to civilplation of
FZQ no,
by hu dPPliMlaoirapemmit subjects Ile epplicanuoa civil penury of
�O nm more than five hundred dollars ($500).
W_rop ❑ Las owner ofthe property, ormy employees with wages as theirsole Inmpeneedon,
a3— will do the work, and the structure is not intended or offered forams (am. T044,Busmass
and Professions Cale: The Contractor's License Law does no, apply to an owner of
property who builds or improves thereon, and who does such work human or through his
awn employees, provided that such improvement are not intended or offered forsde. If,
however, the building or improvement is sold within one year of completion, the owner -
rudder will have the burden of proving that he did not build or improve for purpose of
sale,r
❑ Las owner ofthe property, am exclusively correcting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License law does not apply to an owner o f property who builds or improves t hereon, and
who contracts In such projects with a carnations) liansed punuantmthe Conuacto/a
License Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Data
WORKMAN COMPENSATION DECLARATION
❑ Iberehynffirmlhatlhaveacenificateofwnsentmself-Insure, m iteenfiemsof
Workers' Compensation Irtsumm a ora certified copy thercuf (Sce.3g00. Lab CJ which
coven all y(yeyyu ti tit.
Policy
C,m,m.m.
B Cenifed copy is hereby famished.
❑ CenitieA copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed ifthe p:mdt is frrone hundred dollars ($10(y)
in less.)
I certify that in the affonnsnce of the work for which this permit is issued, I shall
not employ my person in any manner so as to become subject to the Workers'
z Compensation WfwsoCalifornia. Data
Applicant
C) 0 NOTICETO APPLICANT: If. aftermakingthis Certificeteof Exemption, you should
rV) become subject to Ne Workers Compenvuon provisions of Lha Labor Code, you must
^ forthwith comply with such pmvislons or this Permit shall be deemed invoked.
Ix
Z
CONSTRUCTION LENDING AGENCY
I hereby affirm thin mme Is a exromartim lending agency for the peK..r,a of
V O the work for which this psordt is issued (Sec. 301 Civ. G)
L4 r. Lenders Name
C) Li Lender's Address
1 certify that 1 have read this application and shite that the above information is
correct, l agree to comply with Ji city and county ordinances and state laws relating to
V) building construction, and hereby authorize representatives citrus city to enter upon the
L) ,2 abtwe-memioned property far inspection purposes.
(We) agree to save, indemnify and kap molts, the City of Cupertino against
liebillties,judgments, costs and expenses which may in any way accrue against said City
in cnneyuence of the granting of this Permit.
Signature of ApplicanVCormsesor Data
I(AZAR DOUS MATERIALS DISCIASUR I3
Will the applicant or future buil ing a Pentstorcor handle harardcus material
as defined by the Cupertino Muni al Code, Chap¢r 9.12, and the Health and Sakly
Code, Section 255320m))
❑ Yes o
Will the applicant mfuturebmldi accupantne cyuipmenl ordevices which emit
hazardous air contaminant n def by the Bay Area Air Quality Management
District?
❑ Yea o
1 hrvc read the hazardous mornfils na,mremema under Chapter 6.95 of the
California Health & Surety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does nm thready have a tnant,'hut it is my responsibility a notify the
occupant or the requirement which mus' be me' prior to issuance of o Certificate of
Occupancy.
Owner or i nthnrized agent Dat
- USE BALL POINT PEN ONLY
PLUMBING, - MRCIIANICAL
BUILDING PROJECT IDENTIFICATION
IIT# IAT#
OUTSIDE FE4
IN RAC R'S A
„I.IC NO: /.
SCtlCOLTAX
Y N_
RFCE-IPT#
.ELEC7RICPERMIT
PEE-,
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
201 - 1000 AMPS
OVER PRO AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST
POWER DEVICES
SWIMMING POOL ECIRIC
OUTLETS - S CHES-FIXTURES
NEWRES ENTIALELECTR_SQ.FT.
TOT
PLUMBINGIT
PIXT ES - PF.R'IRAP
GAS -E SYSTI3M-I INC.I OUTLETS
GAS - EA. kTpdsrOVER 4(EA)
GREASE TRAP
SEWER - SANITARY - STORM FA. 200F)'.
WATER HATER W/VEN DELECfR
WATER SYSTEM/TREATING
NEW RESIDENTIAL FUME, SQ. IT.
TOTAL:
s MECHANICAL PERMIT FF.H
PERMITISSUANCE
ALTER OR ADD TO MECIL
AIR HANDLING UNIT (T'O 10,0011 CPM)
AIR HANDLING UNIT (OVER IB,fK11) CFM)
EXHAUSTHOOD(W/DUCT)
HEATING UNIT (10 10fp000 B'TU)
ItFATING UNIT (OVER IW," BTU)
VENTILATION FAN (SINGLE RHSID)
BOILER - COMP (311P OR (10,0041 BTU)
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECII. SQ. FT.
26951
❑
- BUILDING PERMIT INFO
'LDG ELECT PLUMB MECH
11, ❑ iA. ❑
W'. i+I
PLANCHECK FEL'
GRADING F13E
SOILS FEE
Ef4HRGY Full
PAID
Data Receipt #
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING ME
MECHANICAL ME
CONSTRUCTION TAX
PAID
Date
]AIV 11 1995
Clry pf i ur�HUN�
IRM110IlrY/
PEE SUMMARY
OUTSIDE FE4
SANI'T'ARY
Y_N
RECEmra
SCtlCOLTAX
Y N_
RFCE-IPT#
PARK FEE
YN_
PLANCHECK FEL'
GRADING F13E
SOILS FEE
Ef4HRGY Full
PAID
Data Receipt #
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING ME
MECHANICAL ME
CONSTRUCTION TAX
PAID
Date
]AIV 11 1995
Clry pf i ur�HUN�
IRM110IlrY/