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99110119APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PING PROD (UT IDEANICAI BUILDING PRU3BCT IDF.NTIFIC BUILDING ADDRESS: r CONTACT. LIC NO: ❑ Consultant Fees Paid by Applicant (Initial) LICENSED CONTRACTOR'S DECLARATION IT I, Z Z I hereby atfno Nm I am licensed under provisions of Chapmr 9 enmmeacing withSection 9(1(10)of DivisionJof Nc Business and Rofessions Cal mid myheareaeix a'r in full farces=d el. ��yS RMI U License qse Lic. k� T h Ixt Q 6 Dute Cmnl scum �_t ,ems rl AN f—� y ARCHITECTS DECLARATION PANEL Z p m Z I understand my plans shall be used its public records O Z.`4— UPTO i4 OWNER -BUILDER DECLARATION Q 1 hereby affirm that I am exempt from the Contractor's License Law for the O y Ufollowing reason. (Section 703 1.5, Business and Professions Code: Any city or county LLu. f— which requires a Permit to construct. ager, improve, demolish, or repair any awemre prim m its tax aonce, also requires the applicant for such permit m file a signal stammem gthat he is licensed pursuant to the provisions of Ne Comracmrs License Law )Chapters) �� (commencing wiNSection 7000) of Division3 of Ne Business and Professiom�Ccde)or yy that he is exempt therefrom and the bans for the alleged exemption. Any violation of NSection 9031.5 by any applicant far a permapplicant it subjects the applicano a civil penalty of nt marc than five hundred dollars ($500). I,aznwner n(Ne properly. or my employee, with wages as theirsole compensation, 1..� willdo Newark, and Nesauctureis not inmmmded uroffetod formic(Sec.TM4, Business Dad Professions Cale: The Contractors License Law does not apply to to owner of p' 3 properly who builds or improves thereon, and who does such work himself or through his own employees provided that such improvements are not intended or offered for sole. If, howesxr. the building or improvement is sold within one year ofcompletion, the owner -builder will have the burden of proving that he did not build or improve for pur- pose of sale.). C 1, as owner of Ne propmy, am exclusively contracting with licenwd comracrors m entrust the project (Sec. 9014, Business and Profcssiona Cede:) The Contrmwrs U- rs, Law does nm apply to an owner of properly who huilds or improve, thereon, and QTY. who contracts for such projects with a comrumor(s) licensed pursuant to Ne Contractor's License Law. I am exempt under Sec. . B & P C for this reason Owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 1 have and wil I maintain a Cerillcam of Consent o self -insure for Worker's Compen- sation. as provided for by Section 3900 of the Labor Code, for the performance of the work r which this permit is issued. eve and will maintain Worker's Compensation Insurance. as required by Section .9W mf the Labs Code. for the performance of @e work for which tha t ed. My Wragh'a CnmrcdacGLhtmrance comer and Paliev member me_ Y�14-t COMPENSATION INSURANCE ('Nis section need not be complcted if the permil is faro. hundred dollars ($I W) or less.) I certify that in the performance of the work for which this permit is issued, l shall not employ any Persian in any manner so as to become subject to the Work ho' Compen- Z satlon Laws of Califnnia. Date 7 O Applicant q M NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should aibecome subject to the Worker's Compensation provisions of the l-ahor Code, you must {47 forthwith comply with such p ..cnmms or this permit shall bo deemed revoked. a CONSTRUCTION LENDING AGENCY U k far. hick tat thin them isaco (Sec. 30 lending agency for Ne performance of {L F the work for which this permit is issued (Sec. 3097. Civ. CJ Q Lender's Nauta Lender's Address yI reffif,e that I have read Nis application and state Nat and above information is N wilding 1 agree to comply with all um and mute oNtisew of end state laws relating he QTY. C.) z above-meconstruction,tioneand herebyamhoruereprexnmtives of this city reenter upon the above-mentioned oto in ertysave for inspection keep ha (We)agmenm save. indemnifyesdhich hay in an way yru Cupenfinar stsid City ist nconiequenc of the expenses which may in any way,acme against City asequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT 501 RC GULATIOj,jI'�S� e Simulate u ' p mVCOn c—lldtmr �Ab HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazeudous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hea06 and Safety Code. Section 25532(0)? ❑Yea �2aO Will Ne applicant or Iature building occupant use equipment or devices which each hazandous air corm anis , as defined by the Bay Areas Air Quality Management Diavia9 / ❑Yes �[jN 1 have read the hzrstrdous materials mPTyimarms undo Chapter 695 of Nc Culi- fomia Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand that if the huddii 7g cs not currently have a tenant, that it is my maporamility 0 notify the occupant of*e iremenRwhlch mmLix, met prior to issuance of a Canute of Oce ... ta . ELECTRICPERMIT FEE UANCE S—RESIDENTIAL SIGNS ELECTRICAI- SEE CIALCIRCUIT/MISC. TEMP. METI3R OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS — S W ITCHES — FIXTURES NEW RESIDENTIAL ELECTR PLUMBING PERMIT PERMIT ISSUANCE ALTER — DRAIN & VENT — WATER (G) B K FLOW PROTECT. DEVICE DRATROOF, AREA, COND. GAS—EA. SYS d-1 INC.4 OUTLETS GAS—EA. SYSTEM VER 4(EA) GREASMNDUSTRI. WA EINTERCEPTOR GREASETRAP SEWER — SANITARY — STORME WIT. WATER HEATER WNENT/ELECTR WATER SYSTEMaREATING WATER SERVICE NEW RESIDENTIAL PLMU SQ. FT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10.000 CPM) AIR HANDLING UNIT (OVER W.1100 CFM) EXHAUST HOOD I WMUCT) HEATING UNIT (TO 100,1100 BTU) lxnK HEATING UNIT (OVER I might BTU) VENTILATION FAN (SINGLE RESID) BOILER — COMP OHP OR 100,000 BTU) BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE gg 1/0 11 PERMIT NO. NITARY NO. I APPLICATION SUBMITTAL DATEI JOB DESCRIPTION RESIDENTIAL C SFDWL /—/�1 ❑ADDITION NIC ❑MULTI -UNIT ❑STRUCTURAL CONTROLN MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT CSWIMMING POOLS C BATH REMODEUREPAIR DEMOLITION ❑ Er .rs `sit �c--F'= BUILDING PERMIT INFO BLDG ELECT PLUMB MECH/ 1:1 El E]2 JOB DESCRIPTION RESIDENTIAL C SFDWL ❑KITCHEN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT CSWIMMING POOLS C BATH REMODEUREPAIR DEMOLITION ❑ Er .rs `sit �c--F'= Wil? AtACp _ COMMERCIAL: El NEW BLDG/ADDITION ❑DEMOLITION [I TENANT FOOD SERVICE IMPROVEMENT - C OTHER PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Data Receipt# AC DING BCL/ u IT ) FEE I MIC FEE 1 91999 ECr UMBING FEE ANICALFEE _ CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Dam Receipt Is TO L: ISSUANCE D TE ISSUED BY: 1 — S/SQ. FT.