21663APPLICANT TO FILL IN INFORMATION
61C
Architect/Engimmn
DECLARATION
Dae Contnctcr
ARCHITECTS DE RA ION
q02 Iunde rldmypbwshallbeusedaspublicremrds.
F
Licensed Professional
�< OWNER -BUILDER DECLARATION
F• Ud 3 1 herebyaffirenthat I am exempt from Ue Contranora LI¢ve Law forthe
pQ following reason. (Section 7015, Business and Professions Code: Any city or
rounty which rsqubesa permit to mmtwn; sher, Improve, demolbh,errtpai,
any stm num, prior to Its issuance, also requ Inn the applicant for such permit to
(5 file a signed statement that he is licensed pursuant to the provisions of the
5'+OC Canfreaor'a Lkenw Law (Chapter 9(mmmencingwith Section 7000)ofDivi.
sb 3o(the Buanmand Profmbe Code)orfhathebexemptthertfromand
S the bub for the alleged exemption. My vlolahon of Section 703115 by say
iccOO appbantf.r.p.r t.b*e theapplicanttoadvilp..Ity.(.O..than
_ five hundred dollen (5500).
C]I, as owner of the property, or my employees with wages as their sale
Ce< compensation, will do the work, and the structure b out Wended or offered for
C O sale (Sec 7064, Business and Profenloro Code: The C ruram/s Lim. Law
p$$ don not apply to an owoar of property who builds or lmpmves themon, and
who doessurhwork himself orthrough hisown employees, provided that such
4npr wnx ms are nm intended or offered for ask. If, however, the building or
bnproweenAt is sold within oneyesre(complef ion, the owner-budderwlB have
tike-hurden of proving that he dm not build or improve for purpose of sale.).
LLj L as owner of the Property, am exclusively oantraeHng with licensed
mntrecton to mmtrYct the project (See. 7044, Busmen ami Prof.Wm Coca:
The Conte acmes License Law don nor apply to an owner of property who
builds or Improve thereon and who contracts for such, IAppets with a
c9niramor(s) boosed pursuant to the Contractors License Law.
L j I am exempt under Sec B k P C for this mown
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby off= that I have a certificate of consent to self -Insure, ce a
cenifiraleof Works CompewHmn lruunn¢yra certified mpy/hemo(�act
3800, Lab C)(' /7 1 IIA f A
�- CERTIFICATE Op EREMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rot becomplefed lfthe pemdt lot¢ cue hundred dollars
(51 OD)or Im.)
I certify Nat in the perfomanceof thework (orwhIch thispermit is Issued,
I 61u0 not employ any person ld say manner w as to became abject to the
Worken'Compsuahon Lava of California. Dae
OZ Applicant
Z NOTICETO APPLICANT:B,ahernaking thisCerttilafeof Exemption,you
Fshould become subpct to the Workers' Compemailon provbbn of the Labor
� N
Code, you rmst(onhwOh comply wlthwNproWlon orthb permit shell be
W "I drenad revoked.
ll � CONSTRUCTION LENDING AGENCY
I hercbyafflrmtlat there b a construction lending agency for the penomr
Z an¢olthe work(or which this pemNtbbwed (See. 3097,CIv. C.)
(� O Lenders Name
LL F- Tenders Aadnm
OW Icertlfyth+ti have read thbapp0utbnand nate ehatthe above information
C bmrrect. Iagres to complywith all muntyordinances and Mate laws
r relating to building mmtmction, and hereby authorise representatives of this
city to elver upon the abovnmentbned property for inspection purposes.
aFlu",
m to nave, loft
Y an d keep harmless the City of Cu penteo
a bNtins, Ndg n[[as nand/`xpensn which may in any, aya sue
. ail nakid Fityinc aaA,, of the/gngtlltJ; mtMsixrtnlL. /_
HAZARDOUSMATFRIALB SURE
Will the appllant or tuWm building bto urhandleharandous
atenvl as defined by Cupertino AC ,Chapter 9.17, and the
m
Health and Safety Code Section 25537(a)I
F1 Y. rj No
Will the applicant or future building occupant use equipment or devices
which emit harardom air contaminants as defined by the Bay Area Ab
Quality Maragenem District?
0 Yes No
• haay�ead the baaa ous materials requiremnb under Chapter 6.95 of
ICalJfg/nla Health k Sef, ode, Sections 25505,75533 and 25534.1
u e thatifthebuil nR 4.
nm Nnsnfly haveatemnt. that ltbmy
D LI - USE BALL POINT PEN ONLY
-�
lIU0 IT NO.
21663
A
CITY OF CUPERTINO-BUILDING DIVISION
l J 6
APPLICATION I PERMIT
BU(LDING-ELECTRICALPLUMBINGMECHAMCAL
CATEGORY
CONTROL#
..r
r' • . ' .ELECTRIC PERMIT. ",FEE
.BUILDING PERMIT INFO,
PERMITISSUANCE
❑ ❑ ❑ C.i
POOL ELECTRIC
ALTER -DRAIN k VENT- WATER (EA)
BACKFLOW PRO=. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
FDCTURFS PER TRAP
GAS EA. SYSTEM -1 INCx1 OUTLETS
GAS PA. SYSTEM1 O V ER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY -STORM EA. 79CFT.
WATER BEATER W/VENT/ELECTR
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. SQ}T.
TOTAL:
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,W0 CFM)
AIR HANDLING UNIT (OVER IOADD CFM)
D(HAUSTHOOD(W/DUCT)
HEATING UNIT (TO 100,0D0 BTU)
HEATING UNIT (OVER 100,DDU BTU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
OFFICE COPY
RECF71'I Y
PARK)# Y_ N_
RECEIPT #
BUILDING DIVISION FEES
PLANCHECK FEE
PAID
Date Recei t#
ENERGY FEE Y N
PAID
Date
Date
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
—TAL:
ItZ TODATE
JAN - z 1931
ISSUEDBY: