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31097APPLICANTTO FILL IN DIVISION J WITHIN RED LINES APPLICATION/PERMIT I hereby affirm that l am licensed undeejrcovislons of Chapter 9 (commencing with Section 705111) of Division 3 of the Business and Professions Code, and my license is in full force and effect. \\ License Class Lic.# Dam Contract., ARCHITECTS DECLARATION ',\ understand my plans shall be used m public amords� - USE BALL POINT PEN ONLY BUILDING -ELECTRICAL PLUMBING - MECHANICAL. BUILDING PROJECT IDEjxFRgCAT10 :ONTRACTOR'S NAME: LP M_�� ' ti . ,S?� S 7 ,DURESS: s s� .sir,, ❑ Consultant Fees Paid by Applicant (Initial) PTY ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS. UPTO 200AMPS 3 y O W U Sd 314 F Y7 LL Iry.�o" a>. a m_pO d q ^ C iYCI or Zsem . OWNER -BUILDER DECLARATION I hereby affirm Nat 1 am exempt frothe Contractors License"Luw far the following ng reason. Serum. 7031.5, Business and Pmftsxianx Code: Any city r county. which requires a peram, m closeout, dor, improve, demnlish' m rept., any\iBucwre priorro its issuance,Aso requires the applicant for such peulitm flea signed ,A en that he is licensed pursuant to the provisions of the Contractor's License Law (C'haptcr\9 (commencing with Sodinn]001) Of Division 3 of the [rosiness and Pmfexsions Code)) rt, that he is exempt therefrom and the basis for the alleged exemption. Any violation at\ Section ](131 1 by eny applicuni for o pemtit subjects the applieml to a civil penalty of, nmore than five hundred dollars (SSW). E]ot I. as owner of the property, or my employees with wages as their sole compensation, PL BUILDING PERMITINFO ' B ELECT PLUM@ MLCIJ 4�(\ p willdmhework, and the structure is not intended reoffered formic (Sm. JOiq Business it Profusxlons Code The Cnmmmnr9 License Low does not apply an an owner of property who builds or improves thereon, and who does such work himself or through JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION, 11 PLUMBING RE -PIPE ❑MULTI -UNIT ❑S'IRUCfURAL MODIFICATION 'INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODELIREPAIR ❑ DEMOLITION - ❑OTHER his own employees, provided shut such intpmvcmemts are am intended or offered for ELECTRIC FEE \\s safe. If. however, the building or improvement is sold withinbne year ofcompletion,the ANICAL FEE �\ N) owner -builder will have the burden of proving Inot he did not build or Improve for our - ,,a of sale.). 4x ". ❑ I, as owner of the property, ma creluovel, nna men , with licensed contmemus to PAID construct the project (Sec. ]Bir, Business and Professions Coal The Contractor's Li. QTY, came Law does not apply to an owner of property who he Ills or improves thereon, and who contracts for such projects with a cotnmaorfs) licensed pursuant o the Commences FEE License Law, ISSUANCE DATE t ISSUED BY, ❑ I mm exempt under Sec. ;R& P C Por this ,assn STORIES eke OCC. OR L U DING DIVISION TYPE CONSTRUCTION APN FEES IdAl//��o��gmp rm owner nae \\ \\ WORKER 'SCOMPENSATION DECLA . 1 heady affirm under penalty of jury one of the fnsum for declarations: following at ampen- p 1 have and will maintain a Cenificvte nl Consent m rel Ginsureior Worker's Cst smiun, us provided far by Section 3]00 of the Labor Cade, for the perf0mmnce of the 0rk for which Nir permit is issued. ' ❑ 1 have and will ummum Worker's Compensation Insurance, as required by Section o 3]00 of the Labor Code, for the performance 01'd a wok for •which this permit is issued. My Woryy�r��C�ItrrgO1ppyyurian in J� rand Policystu�beyrysO Yoo9 Carrier: tatisf 41V fa A. No.: i�J� a_pnlicy CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE C Y (This section need not M completed ifthe Permit is fee.. hundred dollars ($100) at less) I rani ry that in the pertimnance of the wnj¢¢¢k!orw' hthis permit is iseuW,lshell O Z z F -t pJ a �. not mal person in any manner sot caltr'J�'-theWorke,Compen- ,stili Lnwerrjr f -- l�_- y Applicant NOTICE TO APPLICANT: If,making this Cenificato of [acmpdon, you should become subject to the Workers Compensation pmvisionsbf the labor Code, you must forthwith comply with. such provisions or this permit shall he deemed Occulted. CONSTRUCTION LENDING AGENCY Ral U [LF O U �^ ycorrect. U Z 0 len ding agency fonhe peRnmtance of k for whaffrm that there isucmntmct 3097, Om work for which this permit is isxned (Scc.3(19],Civ, Cd Lenders Name Leader's Address 1 ccnify that 1 have constants application and sate the the above information is l agreeordinances comply with all city and county ordinunand state laws relying to building ennstruevil it herebytansaim reprettnsasives ofthi, cityro enmrupon the QTY, abive-mead red property froampeetian purposes. (We) ogree t. save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue ill said City • in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT mgnature Of Apptmamoetmuacnt Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant 01 future building occupant snore orhoodle haxamous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code. Section 25532(a)'t ❑Yea C] No Will the applicant or future building occupant use equipment or devices which emit hmnrdots air contaminants as defined by she Bay Area Air Quality Management Di'lOnO. ❑Yes LD No I have read the fluctuations materials iequiremmis under Chupmr 6.95 of the Cad. burns Health & Safety Code, Sections 25505, 25533 and 25534, 1 understand that i111, building does not currently have a temem, that it is my responsibility to notify the acupant of the requirements which must he "let prior to somneeof a Certificate of Occupunmy. SIGNS ELECPRICAL - SPECIAL CIRCUITIMISC. TEMP. METER OR POLE 1 POWER DEVICES PERMIT PERMIT ISSUANCE BACK SEWER PERMIT ISSUANCE' '/ yr ALTER OR ADD TO M AIR HANDLING UNI'/(171/O,aslJf(NM) AIR HANDLING UNIT (OVER lO.0OR 'F EXHAUST'HOOD(W/DUCf) ' HEATING UNIT (TO 1110,000 BTIJ) HEATING UNIT (OVER 100.0001 BTI VENTILATION FAN (SINGLE RISID) BOILER - COMP LHP OR 100,000 B'TO) MOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL. MECH. OFFICE 1097 .1 ❑. PL BUILDING PERMITINFO ' B ELECT PLUM@ MLCIJ 4�(\ \ \\ TOTAL:! FEE JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION, 11 PLUMBING RE -PIPE ❑MULTI -UNIT ❑S'IRUCfURAL MODIFICATION 'INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODELIREPAIR ❑ DEMOLITION - ❑OTHER SEISMIC PEE �\ ELECTRIC FEE \\s P BING FEE �\ �0 ANICAL FEE �\ N) NSTRUCTIONTAX COMMERCIAL: - ❑NEWBLDG/ADDITION ❑DEMOLITION E] TENANT ❑FOODSERVICE �. IMPROVEMENT v ❑ OTHER 4x ". PAID s Dam Receipt# SQ. FE FLOOR AREA VSQ. Fr, .. r ~ MAR 17' arcA'1'I Ur t;uM�'H�'INALUNU FEE ISSUANCE DATE t ISSUED BY, n o I,` on .p c STORIES eke OCC. OR L U DING DIVISION TYPE CONSTRUCTION APN FEES IdAl//��o��gmp rm \\ \\ PLANCHI F ENERGY o SOAKS FEE _• PAID\ - PL 4 u \U to -• Rmpt# \\ \ \\ TOTAL:! )IAL: BUILDING FCL' �\ SEISMIC PEE �\ ELECTRIC FEE \\s P BING FEE �\ �0 ANICAL FEE �\ N) NSTRUCTIONTAX Or JSING MITIGATION ITE V Y PAID Dam Receipt# TOTAL: ISSUANCE DATE t ISSUED BY, SQ. TOTAALL :