25370TY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
5 f3oy wood D►^
R, Breaks (hail
LICENSED CONTRACfOR'S DECLARATION
ay.y I hereby affirm that l em licensed underpmvisionsofC apter9(commencing with
POLI Sectilifting 0) of Division 3 of the Business and Professions Code, and my license is in
Fy� m fall folic ital etfect.
6V Liwnsc Class LLCM
yQy Date Contractor
ZOyZ ARCHITECTS DECLARATION
O Z—n I undemand my plans shall h ued es public records.
r rat;
i...4I Licensed Professional
a�U OWNER -BUILDER DECLARATION
Oyu 1 hereby affirm that 1 am exnnpt train the Conoacmrs License Law for the
W13 ym¢ followingreasan.(Section 7031.5. Business and pumminns Code: Any city m county
F" ° J which requires a Permit to construct, alter, improve, demolish, or repair any nrucmre
prior to its issuance, also requires the applicant for such Permit to file augured statement
GO that be is licensed pursuant to the provisions of the Contractor's License Law (Chapter
y o ' 9(commencing with Section 7") of Division 3 ofthe Business and Professions Cade)
y,_y or that he is exempt herefrom and the brans for the at leged exemption. Any violation of
u Z Q Section 903 1.5 by any applicant for a permit subjects the and ca t to a civil pcnahy of
not marc thin five hundred dollars ($500).
❑ I,mownerMthe property, ormyemployeeswiN wageaastheirsole mulasosotinn.
y will dome work, and the suucmm isnot intended oroffeed fairings (Sao 7041. Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and whodues such workhimselforthrough his
ownemployars, provided that such improvements are not intended muttered formle. If,
howeveg tlm bu'ddingor improvement Is sold within one yeurofeompletlon, the ownin,
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner nfthe profanity, am exclusively contracting with licensed contractor, to
construct the project (Sec. 70114, Business and professions Code:) The Cantmetora
License Law does not apply to an owner of property who builds or improves the mm, and
whocrntracts for such Projects with acontractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am excmpt under Seo. , B & PC for this reason
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that l haveacrnificate ofconsenttoulf-insure.oracenificamof
Workers' Compensation Imurance or a certified copy thereof( See. 3800. Lab C) which
s all employce'.v under rM1is permit.
Policy #
Company
❑ Certified copy is hereby ids the city
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF BXEMPPION FROM WORKERS'
COMPFNSAT'ION INSURANCE
(This m,, ion neral mot be completed it Obtaining is fmr ane hundred dollen($100)
a.)
I certify that in the performance rthe work for which this permit is issued,! shall
not employ any peon in any manner so is m become subject to the Workers
ZCompensation Laws of California. Dote
Applicant
NOTICE TO APPLICANT If. after making this Cenificme of Exemption, you should
t'" > forthwith comply
the such
por Conger, this pmvistansobe cooked. matt
> forthwith comply with each provisions nr this permit shall be deemed revoked.
yD CONSTRUCTION LENDING AGENCY
a z Ihereby affirm that Here is a construction leading agency for the performance of
U O the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Of_t Lender's Address
WI cenllY Our 1 have read this npplic.don and stere that the above information Is
cored l agree to comply with all city and county ordinances and stare laws relatingto
,0 building construction, and hereby amhonm representatives of this city to enter upon the
U Z above-mentioned property for impaction purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this it.
remm of ppE anav'mtracmr Date—
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hi ardour material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Sectlmn 25532(o)R
❑ Yea, ❑ No
�
Willing, the applicant or furore building occupant um equiNnrnt or devices which emit harafdous air conmmirwts m defined by the Bay Ates Air Quality Management
Dis ctT
❑ Yes ❑ No
I have read the haaardom mamriala ownirements code, Chapter 695 of the
California I Iealth & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
ifthe building does not curren0y have a maant, Nat it is my responsibility to nmify the
occupant of the requirements which most le met lino! to iamaace of a Certificate of
Occupancy.
Owner or nuNonsc l agent Data
POINT PEN ONLY
ELECTRIC PERMIT
PERMIT ISSUANCE.
APPLIANCES - RESIDENTIAL
PANELS
UP 10 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR MIX, INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OIJ'I'LETS - SWITCHES - IRXTL
NEW RESIDENTIAL F:LHCTR .
PLUMBING PERMIT
PERMIT ISSUANCE
AI,TER - DRAIN & V17NT - WATER (EA)
BACK FLOW PROTECT, DEVICE
DRAINS - FLOOR, ROOF. AREA, COND.
FIXTURES - PER TRAP
GAS - PA. SYSTEM -1 INC. 4 OUTLETS
GAS- EA. SYSTKkbOVHR 4 IRA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - S1 ORM FA. 200F1.
WA'IUR HEATER W/VF.NT/F.LECTR
WATER SYSTEM TRP.ATING
NEW RESIDENTIAL PLMB. SQ. Ff.
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTHR OR ADD TO MECH.
AIR IIANDLING UNIT (TO 10,000 CFM)
AIR IIANDLING UNIT (OVER 10,000 CPM)
EXHA US'T HOOD(W/DUCT)
I [RATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I00,00h) BTU)
VEN'I'I LAI ]ON PAN St NOLE RESID)
BOILER - COMP (311F OR 100,000 BTU)
BOILER - COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MI.CH. SQ. Ie,'.
TOTAL:
IN 25370
SANITARY NO. APPLEA'RON SUBMITTAL DATE
—QAC NO:
N/C CONTROLM
EEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ `E. ❑ ❑
JOB DESCRIPTION
sQr�
SQ. FI'. FLOOR AREA E/SQ. FT.
r.-) 6Nas,
FEE
FEL?
SCHOOLTAX
PARK FEE
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
(late
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING F13E
MECHANICAL. FEE
CONSTRUCTIONTAX
PAID
Data
ISSUED
SUMMARY
Y N