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99110040FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY BUILDING DIVISION APPLICATION/PERMIT IILDING ADDRESS: lb5bl ❑ Consultant Fees Paid by Applicant (Initial) 1 hereby affirm shat I am licensed under provisions of Chapter 9 (commencing in with Section70W)of Dl vision 3 ludic Business and Profession, Code, uad my license is FU-�� in full force and eliect 11 U tom,) Ltceasc Che Lir,g� 1� T- Z (y Dale Contreanr H°Q L AR HITECI'S DECLARATION F n z i understmid my plans shall be used as public recoNs oz —0 h•,�E w Licensed profes,imul OWNER -BUILDER DECLARATION 6 1 hereby aRrm that I am exempt from the Cantraaors License Law for she O y U following reason. (Section 1031,5, Business and Professions Code: Any cid, or county m OT- which requires a permit to consumed, cher, improve, demolish, or repair any sumcmre prior to its issuance, also requires the applicant (orsuch permit to file a signed statement ;tW!�jy that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9 W C (commencing with Section 7") of Division 3 ofthe Business and Professions Cartel or q e gthat he I, exempt therefrom and the basis far the alleged exemption. Any violation of — so Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of Z } not more than five hundred dollars ($5001. dQ D i, a, owner of the properly, or my employaas with wages as their sole compensation, will do the work, and timinunuu is not intended oroffamd for We(See 7044, Business and professions Code: The Contrdcmr'x License Law does not apply to an owner of properly who builds or improves thereon. and who does such work himself or through his own employees, provided that such improvements art not intended or offered for sale. If, however the building or improvement Is sold within one year of completion, the wnerbuilder will have the burden of proving that he did not Wild or improve for par - pose of sale.). D 1, as owner of the property, am exclusively contracting with licensed contrarian to consumed the project (Sec. 7014, Business and Professions Cok:) The Contmctio s Li- cense Law does not apply to an owner of properly who builds or improves thereon, and QW.. who contracts for such projects with a contractors) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec. , B & P C for this reason ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 200 AMPS SIGNS ELECTRICAL SPECIALCIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS _ SWITCHES - FIKj NEW RESIDENTIAL. ELECTR Owner Date WORKER'S COMPENSATION DECLARATION 1 heraby affirm under penalty of perjury ane of the following declarations: 1 have and will mai nmin a Car ifcate of Consent to self -insure for Walker's Compen- sation, as provided for by Section 37W of the Lada Code, for the performance of the 1rk for which this permit is issued. I have and will maintain Workers Compensation Insurance, as required by Section l ufdhe Labor Cade, for the performance Uthe work for which this permit is issued. My WorlYscs C/ttpp t"t s heartier and Policy n�nsbwttp. .��A�11 Cariee i�YV KkT 1 Policy No.: 1'S�Y 1.-----e�1 ^T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need nm be completed if the pmnis is for one hundred dollars (5100) orless.) I cenlfy that in the perliamance of the work for which this permit is issued, I shall not employ any person in any manner so os to become subjecna the Workers Compen- Oz action Lawlor California. Data Z O Applicant ` ray h NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should a 7 become subject do the Workers Compensation prwi,iom of the labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. Q CONSTRUCTION LENDING AGENCY U 0 work hick thi that isacomwetionlending agency for the performance of i1, E-' thework far which this permit is issued (Scu. 31197, Civ. CJ Q U Leaders Name LenJcrI Address IY 1 rarity that 1 have read all thisapplicationand state that the shove information g is ,oIZ cement, l agree ic comply with all city and county ordinances and state laws relininghe Q'(g U Z move-menrmaudiomaad hereby authonureoses. moves of thio city to enter upon the move -mentioned gra progeny forinspectionapurposes. (We) agree m save, indemnify and keep truly in an the City of Cupertino id City liabiliiles,juJgments, costs mid exppPtQQ�� which may in any way uccme against evil City in consequence of the ,B,nranyng of malt. APPLICANT IIt4DEryxT t4�5 A D WILL COMPLY WITH ALL NON -POINT V HAZARDOUS MATERIALS DISCLOSURE - Wiil the applicant or furore building oecupunt smm or handle bar Mmus material u defned by Ne Cupertino Municipal Cale. Chapter 9.12, and the Health and Safety 3odc, Section 25532(a)7 � D 4 Yes 9- kWill the applicant or future building occupant a,, equipment or device, which t harrdums air contaminants a defined by the Bay Area Air Quality Management isoict? ❑Yes No I have tcadme It dour incl elsrequlromeme under Chapter 6.95 of the Cali forma Health & Safety Cak, Saban'I25505, 25533 and 25534.1 understated Nat if the building dues not/a�(� /y eu rat ,,bar it is my responsibility do notify th{cecupant of the mauire, dhi� u{thArm prium ixm.a of a Cenifeptgtfl'jkQiyagey. PLUMBING PERMIT PERMIT ISSUANCE ALTER -DRAIN & VENT- WATER (EA) BACK FLOW PROTECT. D17VTCH DRAINS- FLOOR. ROOF, AREA, COND. FIXTURES - PER TRAP GAS- EA. SYSTEM.) INC. 4 OUTLETS GAS - F.A. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER - SANITARY - STORM EA. 200 FE WATER HEATER W/VENDELECTR WATER SYSTENUTREATING WATER SERVICE NEW RESIDENTIAL PLM9. SQ. ET. MECHANICAL PERMIT PERMIT ISSUANCE AL'I'17R OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFMI AIR HANDLING UNIT tOVER 10,000 CFM) EXHAUS'I'HOOD IW/DUCT) HEAPING UNIT (TO 1001p(1 BTU) HEATING UNIT (OVER 100.000 BTU) VENTILATION PAN (SINGLE RESID) BOILER -COMP (3HP OR 1 W,(YBTU) BOILER - COMP (OVER I Wp00 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FF. OFFICE TOTAL. U''V FEE 3bgj3o59 BUILDING DIVISION FEES PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Dale Receipt g T L: BUILWAFEE r— FEE 5E15 FE9, JQQCh ELECHIC FEE PLU RING FEE MEC ANI AL -FE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Receipt is TOTAL Y ISSUADATE l/- q g 9 BUILDING PERMIT INFO - BLDG ELECTPLU B MECH 13 E] PUP FEE JOB DESCRIPTION RFSIDENTIAL: O SFDWL C KITCHEN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT El STRUCTURAL MODIFICATION C INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT CSWIMMING POOLS D BATH REMODEUREP IR (] DEMOLITION ❑OTHER COMMERCIAL ONEWBLDG/ADDITION DDEMOLITION OTENANT OFOOD SERVICE IMPROVEMENT C OTHER SQ. ff. FLOOR AREA SISQ. FT. FEE 3bgj3o59 BUILDING DIVISION FEES PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Dale Receipt g T L: BUILWAFEE r— FEE 5E15 FE9, JQQCh ELECHIC FEE PLU RING FEE MEC ANI AL -FE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Receipt is TOTAL Y ISSUADATE l/- q g 9