S 4346FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
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nUILU1NC DR'ISION APPLICATION/PERMIT 1'LUM1IftINI; MECHANICAL S 4346
ItIII1111NC pinto C I lisp NII]ATION
'LON'fACI': PITON is lif'Jlr
.rr�oL•Lj ❑Consultant Foes Paid by Applicant (Initial)
V C
r,F
LICENSED CONTRACT'OR'S DECLARATION QTY
1 hereby affnn that 1 am licensed under provisions of Chapter 9 (commencing
�OZO with Section T(Xp)ol Uivisiun3uf Ne Business and Pm ssi9ps Crgff,.ln``mylicensc is
, W 2 in lull force and effect. C , I q
QUU Lonm Cb ss p
hzw aw Dale Conlmcm
ARCHITF.CI'S DECLARATION
~ v Z 1 undennard muse
y plana shall be d e, ahre acco do
OZ -a
E. N F W Licensed 11rofessionel
OWNER -BUILDER DECLARATION
C o 0 6 I hereby affirm that 1 am exempt from the Contremnr's License Law the
XO a U following arson. (Section 7031.5. Business and Professions Coolie Any city o unty
W 3 Us y which require, a permit to construct. olrcr, improve, demolish, or repair any
cj prior m its issuance, also requires the applicant fm such pe.iuo file a signedstateme
2 >• that he is licensed pursuant to the pnrvkrus of the Contractor's License ].use (Chapter 9
a�00 (commencing with Section 700(rof Division 3ofthe Businessmd Ptofessiovo Cnd0or
6 w c tY Net he is exempt therefrom and the basis liar the alleged exemption. Any violation of
wSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
nut mare man live hundred radars 14500.
SSC ❑I. as owner of the property. or my employees with wages as their sole compensation,
1., will Jo the work, and the srmemm is not intended or offer Of far sale (See 21W4, Basi nes,
a 3 m and Profmsions Codc:'Me Contractor's License Law dm% not apply to an owner of
property who builds or improves thereon, and who does such work himself nr through
his own employees, provided that such improvements are not intended or offered for
sale. If, hmvever, the building ur improvement is sold within one yen of rvmpletinn, the
erbuilder will have the burden of proving that he did not build or improve for pur-
po a Of vlcJ.
0 1, as Owner of the propenX am exclusively contracting with licensed contractors no
nnstruct the project (Sec. ](W, Bstness and Pmfewions Code',) Tae Comnu....%Li-
erase Law done, not apply to an owner of propcny who builds or improves thereon, and QTY.
who counters for such propriety with a contractor(,) derawd pursuant to the Crnnadors
License law'.
❑ 1 am exempt under See. . II & P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affrm under penalty of perjury one til'the following duclwdium:
1 have and will maintain a Cmificate of Consent to s R-insumforWorkersCoagen-
717"'W")"'f
llnn, s provided far by Senior 3700 of the labor Gds, for the perfunnnnce —the
eek far which ,his permit is issued.
1 have and will maintain Workers Compensation Insurance, asreyulred by Section
the Labor Code, for the nertOrmancc of the workkY.fi4or whichthispenultis issued.
ymerr oro en: ai m sur tics carie and Polcy Nce`a nor
I:RTIPICAl1:OF 17XEMPI ION FROM WORKERS'
COMPENSATION INSURANCE
(This sceinn red not lscompleled if the penult is I'nnmr hundred d011an (Elq)1
or Tess.)
1 certify that in the performunce of he work far which Ihi,,cord is issued I shall
not employ any person in any manner sn as to become subject o the Workeri Compere
O 'Z ration Wws of Cmifa.m Da d
Q Applicant
Zr fn NOTICETOAPPLICANT:II; Compensation
this Ceniticmftil Exemption,youshould
? hecomoln comply
y the Worker'sh pro Compensation pmvisians of ,he labor Code• you mux,
� Emhwifh comply with such provisions or this pxnnil shall he deemed revoked.
d
CONSTRUCTION LENDING AGIiNCY
U 0 t hereby a0lrm that there is a catiamnian lending agency for the Performance of
k. F the work for which this penal is ismer (Sec. 3097. Civ. C.)
O U Lender's Name
r W Lundcrs Address
C 1 cenify thin 1 have read this application and state fhurthe above information is
Hy meal l agmen comply with all city and county ordinances and state laws relating it)
U Z budding construction, and hereby animates representatives of this city to enter upon the
above-mentioned property for inslechou purpows.
(Wc) agree ns save, indemnify and keep hannless,he City of Cupertino against
liabilities. judgments, rigid, and expenses which may in any way accrue xgmn.or said City
in
mf1s6amence Of the granting
of this
.1lproumyi',. �1 `.�1 /.1(� t/��1/{;
SO
APPLICANT
RE1 LJJAni)S� 1l A 2. 11 LV WITH
(RlaI I IALL I.
IIAZARWIIS NIAIER1ALS DISCLOSURE.
Will the applicant or future building meupant store or handle lmzmJnus material
, let! act by the Cupertino Municipal Cod& Chapter 9.12, and the Health and Safety
Code, Seen,. 23532(.)1
❑Yes [I No,
'm Will the applicant or future building occupant use equipment or devices which
it hnuNous air mmannin me, as defined by the Bay Are. Air Quality Management
❑Yes E] NO
1 have mail the Infamous mamriols requirements under Chapter 6.95 of the Call-
Inmiu Health & Safety Code, Scotian, 25505, 25.533 and 25534. 1 understand that if the
bnilmirm dues am cum nofv have a fenW that iI is my responsibility to nom dr Ne Occupant
M
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES — RESIDENTIAL.
PANELS
POWER DEVICESv /
SWIMMING POOL, ELECTRIC
OUTLLrS— SWI TCHES— FIST URIS s
NEW RESIDENTIAL ELECIR SQ lel'.
PLUMBING
AU] 'ER—DIi6L) . —W' t(EA
BACK (LIR PR EM! I!
DRAINS — IT. OH )F EA.
FIXTURES—PERTRAP C i
GAS—EA. SYSTEM -1 INC. 40 S
GAS — EA. SYSTEM -OVER 4 (EA)
GREASEIINDUSTRL WAST12 INTERCCI'TOR
GREASEIRAP
SEWER—SANITARY—STORM EA. 20() FT.
WATER HEATER WIVIiNVIi1.ECFR
WATER SYSTF.MO1REAfIN1.
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ, FT.
T(
QTY. MECHANICALPERMIT^
PIiRMI'I'ISSUANCE: S 1
ALTlilt OR ADD 'IO MECH. �• y
AIR HANDLING UNIT(]() 10,00001M)
AIR HANDLING UNIT (OVER 10.00)CFM)
17XIIAUS'IHOOD (W/DUCT)
BEATING UNI'(' TO 110,()fl0 BTU)
I IF.AUNG UNIT (OVER 100.0011 BTU(
VENTILATION FAN (SINGLE RESID)
BOILER—COMP (AIV OR 100.(X0 BT31)
BOILER—COMP(OVER 101TO(PBTU)
AIR CONDITIONER
NEW RESIDENTIALMF.CH. Si ET.
OFFICE
FEE
FEE
ral
mwlY
BUILDING P
BLDG IiLECI' i
JOB DESCRIPTION
RESIDENTIAL•
❑SFDWL
❑ KITCHEN REMODEL
L3 ADDITION
O PLUMBING RE-PIPF.
❑MULTI -UNIT
F1 STRUCTURAL
PLUMBING .'
MODIFICATION
Q INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
(] SWIMMING POOLS
❑ BATH REMODEUREPAIR
❑ DEMOLITION
[]OTHER
��JPAID
COMMERCIAL,
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
SQ, FT. FLOOR AREA
n,2_63
2S/RI'/ z)
BUILDING DIVISION FEES
Date
—
BUILDING FEE sr'
FEE
SEISMIC FEE 7 1
ELECTRIC FEE
_ a
PLUMBING .'
MECIIA l
CON )N TAX
HOUSI ITIGATION FES
��JPAID
Dam RuelptM
ISSUANCE DATE
a - Z Q
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