27629CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
3UILDING ADDRESS:
UNIT#
LICENSED CONTRACTOR'S DECLARATION
Matz Iherehyvffirmthat l smlicemed under provisions odChopter 9(commencing with
410a10Section 7")of Division 3 ofthe Business and Professions Code, and my licemse is in
p, Efull to. ad effect.
<, License Class Us.#
rat<y DareCo.W,
�voz ARCHITECTS DECLARATION
Z 1 understand my plans shall be used as public records.
LA
Licensed Professional
K W OWNER -BUILDER DECLARATION
Oyu 1 hereby ti thus 1 am exempt from the Contractor's License Law for the
3 a ma following reason. (Section 703 L5, Business and Professions Code: Any city or county
1, 10J which requires v permit to construct, alter, improve, demolish, or repair any structure
phot to its issuance, also requiondas pdierm,far such poor, to file a sigrodcatetrtent
0 that he is licensed pursuant to the provisions of the Contactors License law (Chapter
0.p 9(commencing with Section 7") of Division 3 of the Bosimss and Professions Code)
W ern or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
taQ Section 7031.5 by any applicant for apc.it subjects the epplicantme civil penalty of
W,S mor mare than five hundred dollars ($500).
w ❑ I. ss ownerofthe property, or my employees with wages m theirsole comprnsadan,
a will do she work, and the structure is not intended or offered for safe (See. 7044, Bus
and Professions Code: The Contractors License Law does not apply w an owner of
property whobaildsofimpow. Merton, and whodo amelawork hinwelfor Waugh his
own employees, provided that such improvements an no, intended or offered for sale. If,
however. the building or improvement is sold within one year of completion, me owner -
builder will have the burden of proving that he did not build or improve for purpose of
fth
wneroe property, am exclusively contacting with licensed mountains to
onswa the pro cat (Sec. 7014, Business and Professions Code:) The Contactors
nama Law does not apply to an owner of property who builds or improve tla rmn, and
who contracts for such pmjeca with a connections) licensed purseant tothe cmum oes
License Law.
❑ 1 con exempt under Sec._, B & P C for this reason
- WORKMAN COMPENSATION DECLARATION
❑ Thereby off that l have u certificate ofwnsent to self-morm, or a canificate of
WorkealCmeetion Imuancermit. fied copy thereof (Sec. JBBB, Lab CJ which
raven all employee's under This permit.
Policy q
Company
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city impecrion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This m,,lum meed notbecompleted if the permit is Rome hundred dollars ($IOW)
tor less.)
1 ccnify shot in the pMomiance oI work for which this Permit is issued, l shell
not employ any person in any rronner so as to become subject to, the Workers'
z Compensmionlawsof Colifomia. Due
Applicant
0 NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
M become subject in the Workers Compensation provisions of the Labor Code, you must
I^ fnnhwith comply with such arm,, fit., or this pemtil shell be deemed revoked.
0.Q CONSTRUCTION LENDING AGENCY
U z I hereby affirm that there is e construction lending agency forthe performance of
U 0 the work for which this Permit is issued(Sm. 3097, Cu. C.)
Unader's Name
Lender's Address
j I certify that 1 have read this application and state that the above information is
>, Gla correct. l same to comply with all city and county ordinance and sale laws miming to
1 building construction, and herebyrulumiu representatives of this city to arm, upon the
U ,Z, above-mentioned pmpeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabiliries,judgments.cnstsanJ expenses which may in any way acemeagainst said City
in consequence of the granting of this permit.
Signature of Applicunt/Concescmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Iuare building occupant store or handle hazardous material
us defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(0)7
MYes ❑ No
Will meaa,plicant or forme buildtngwcupunt use equipment ordevices which emit
huardom air conundrums as defined by the Bay Area Air Quality Management
Divides?
Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Cade, Sections 25505, 25533 and 25534. 1 undersand that
ifthebuild' of currently have a ant. that it is my responsibility to notify the
atopens s ne
amens whWh must he met prior to issuance of a Cmifie_te of
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES . FIXTURES
NEW RESIDENTIAL ELECTR _SQ. FT.
TOTAL:
PLUMBING PERMIT FEE FLOO
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE SANITARY
DRAIN -FLOOR,R F, AREA,(OND. 1• SCHOOL TAX
FIXTURES�-ER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRI. WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM M. 2WFT.
WATER HEATER W/VENT/ELECTR
WATER SYSTENDTI EATING
NEW RESIDENTIAL PLMIL SQ. PT.
M, ANICAL PERMIT FEE
I'MrISSUANCE
AL ROR ADD TO MECH.
R HANDLING UNIT (TO OO CFM)
AIR HANDLING UN O 00 CEM)
EXHAUST HOOD (W/D
HEATING UNI" ," BTU)
HEAT) (OVER 10(1,1X)0 BTU
FAN(SIN 1
BE R-COh (3HP0 0 BTU)
BOILE -COMPO 110,0410 BTU)
NEW RES ENTIAL MECH. O. FT.
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY HE
FEE SUMMARY
Y N�
RECEIPT#
V N
PAID
Data Receipt If
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL ME
CONSTRUCTIONTAX
PAID
Date
ISSUED BY:
'MAD
JAN 1919,,
car r : R
27629 / 6 /Q
L 1 V L V
I:NT'1'IFICATION
OT#
SANITARY NO.
APPLIC1AITIIONSUUBMITI'ALDATE
s LIC
V
N/C
❑
CONTROI.q
T
-
FEF
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
❑ ❑ atf— ❑
.M�/ JOB DESCRIPTION
W^ /ZV.)
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES . FIXTURES
NEW RESIDENTIAL ELECTR _SQ. FT.
TOTAL:
PLUMBING PERMIT FEE FLOO
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE SANITARY
DRAIN -FLOOR,R F, AREA,(OND. 1• SCHOOL TAX
FIXTURES�-ER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRI. WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM M. 2WFT.
WATER HEATER W/VENT/ELECTR
WATER SYSTENDTI EATING
NEW RESIDENTIAL PLMIL SQ. PT.
M, ANICAL PERMIT FEE
I'MrISSUANCE
AL ROR ADD TO MECH.
R HANDLING UNIT (TO OO CFM)
AIR HANDLING UN O 00 CEM)
EXHAUST HOOD (W/D
HEATING UNI" ," BTU)
HEAT) (OVER 10(1,1X)0 BTU
FAN(SIN 1
BE R-COh (3HP0 0 BTU)
BOILE -COMPO 110,0410 BTU)
NEW RES ENTIAL MECH. O. FT.
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY HE
FEE SUMMARY
Y N�
RECEIPT#
V N
PAID
Data Receipt If
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL ME
CONSTRUCTIONTAX
PAID
Date
ISSUED BY:
'MAD
JAN 1919,,
car r : R