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29360APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF, CUPERTINO -- BUILDING -ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANiCAI 640 TP.Hn06TT8 Coco 2 i 'fp Licensed Professional •6-•]I OWNER -BUILDER DECLARATION I hereby affirm that 1 our exempt from the Contmctur's License Law for the L F following reason. (Section 7031s. Business and Professions Carlo Any city is, county y which minims a Permit to construct, alter, improve, demolish, or repair any structure n] prior to its issuancaelso requires thcapplicant fur such permitto file is signed statement that he is licensed pursuatn m the provisions of the Co dowun's License taw (Chaptar9 ]O (commencing with Section 7000) of Division 3 ofthe Br iness and Professions Color or p� that he is exempt therefrom and the basis for Tie alleged exemption. Any violation of ,^, m Section ]03 LS by any applicant for a permit subjects the applicant to a civil penalty of qD, um more Nan five hundred dollars ($500). C� D 1, ax owner nl the pmpcny, nr my entpinyces witb wugrs as their wle compensation, will do the work, and the structure is not intended or offered for are (Sec. 7044, Business Cm and Professions Cale: The Contractors License Law does tan apply or ea owner of property who builds or Improve., mention, and who dos such work himself or through hist employees, provided that such improvements um not intended or offered for sale own however, the building or improvement is sold within one year of completion, the ter -builder will have the burden of proving that he did not build or improve for pur- po m J.. owner of the properly, am exclusively contracting with licensed contractors Fct me pri (Sea 7044, Business and Probvidens Code:) The Contmnnr's Li. cense law does not apply to an owner of piapcny who builds or improves thereon, and QTY who contracts for such projects with a commands) licensed puauam to the Contmnor's License Law, I" ❑ Imna'Amemoergee. A' s B&P C Ovthls reason OVER TEMP, METER OR POLE INS'('. POWER DEVICES SWIMMING POOL ELECTRIC OUTLET S - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTS - SO FT PLUMBING PERMIT �.vnc Dae CUNIAnf- rnunc: •� 447-6s.5--3 ❑ Consultant Fees Paid by Applicant (Initial) BACK FLOW PROTECT, DEVICE iM I� 'N S5_ 3z DRAINS -FLOOR, ROOF.AREAI COND. LICENSEDCONTRACTOR'S DhCLARATION QTY ELIiCI'RIC PERMIT FIXTURES - PER TRAP work for which this permit is issued. I I herehy aBtrm mm I am licensed under provnstons of Chapter 9 (commenenng �. GAS - IIA. SYSTEM -1 INC. 4 OUTLETS rZ whirs cction7WO) od Drvtsmn 3 ofthe Business and Professions Code, and my license is CERTIFICATE. OF EXEMPTION FROM WORKERS' - INSURANCE. DC) in - PERMI I ISSUANCE V APPLIANCES - RESIDENTIAL )r Liail cense Classurce Lit. License Class Cmde - Date contractor " sation Laws of California. Date Applicant ARCHITF:CI'S DECLARATION PANELS " forthwith comply with such provisinnser tics pe fail shall be deem of revoked. 1 understand my pfins,hut he used iipublicretords CONSTRUCTION LENDING AGENCY � •' DP'IU 2IXIAMPS ' 'fp Licensed Professional •6-•]I OWNER -BUILDER DECLARATION I hereby affirm that 1 our exempt from the Contmctur's License Law for the L F following reason. (Section 7031s. Business and Professions Carlo Any city is, county y which minims a Permit to construct, alter, improve, demolish, or repair any structure n] prior to its issuancaelso requires thcapplicant fur such permitto file is signed statement that he is licensed pursuatn m the provisions of the Co dowun's License taw (Chaptar9 ]O (commencing with Section 7000) of Division 3 ofthe Br iness and Professions Color or p� that he is exempt therefrom and the basis for Tie alleged exemption. Any violation of ,^, m Section ]03 LS by any applicant for a permit subjects the applicant to a civil penalty of qD, um more Nan five hundred dollars ($500). C� D 1, ax owner nl the pmpcny, nr my entpinyces witb wugrs as their wle compensation, will do the work, and the structure is not intended or offered for are (Sec. 7044, Business Cm and Professions Cale: The Contractors License Law does tan apply or ea owner of property who builds or Improve., mention, and who dos such work himself or through hist employees, provided that such improvements um not intended or offered for sale own however, the building or improvement is sold within one year of completion, the ter -builder will have the burden of proving that he did not build or improve for pur- po m J.. owner of the properly, am exclusively contracting with licensed contractors Fct me pri (Sea 7044, Business and Probvidens Code:) The Contmnnr's Li. cense law does not apply to an owner of piapcny who builds or improves thereon, and QTY who contracts for such projects with a commands) licensed puauam to the Contmnor's License Law, I" ❑ Imna'Amemoergee. A' s B&P C Ovthls reason OVER TEMP, METER OR POLE INS'('. POWER DEVICES SWIMMING POOL ELECTRIC OUTLET S - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTS - SO FT PLUMBING PERMIT �.vnc Dae A1.1'EN-UNAIN&VBNT TE -WATER A) ' WORKER:4COMPIi ATIONDIiCLARATION BACK FLOW PROTECT, DEVICE I hereby affmn under penalty of ritay one refine following declarations: DRAINS -FLOOR, ROOF.AREAI COND. ❑ I have and will maintain a Certificme of Consent to sell -insum for Workers Campers- cation, as provided for by Section 3]0) i)1 the Labor Code. for the performance of me FIXTURES - PER TRAP work for which this permit is issued. I 1 have and will maimam Workers Compensation Insurance, as required by Section 3700 of the Labor Cade, for performance mfthe work lot which this permit is issued. �. GAS - IIA. SYSTEM -1 INC. 4 OUTLETS My Worker's Compensation Insurance canter and Policy number rum Camec Policy No.: - GAS -EA. SYSTEM -OVER 4 (EA) CERTIFICATE. OF EXEMPTION FROM WORKERS' - INSURANCE. GRP.AS[%INDUS'fRL WASTE INTERCEPTORCOMPENSATION (Thissectionneed not becompleted ifthepermit isomers, hundneddnllars($100) or les,.) GRP,ASETRAP SEWLN-SANT"1'ARY-STORM EA:2IXI FT. 1 certify that in the performance of the work for which this permit is issued. l shall meemploymtypenoninanymanmersn ms o became subject to the Worker,' Conopen- WATER HGAI'I:N W/VENTIELEC'1'R sation Laws of California. Date Applicant NOTICE TO APPLICANT: If, aper making this Ccnificate of Exemption: you should became subject to the Worker's Compensation previsions of the Labor Coda, you must WATER SYSTEM/TREATING - forthwith comply with such provisinnser tics pe fail shall be deem of revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ. PT. I hereby affirm that there is a construction lending agency forte performance of the work for which this permit is issued iSre. 3097, Civ. C.) Lender's Name sire Lenders Address TOTAL'. -1 certify that 1 have mud this application and state mat the above information is QTY. MECI IANICAL PERMIT correct. I agree in comply with all city and county ordinances unit some lawsmintingto building cansruaion, and hereby authorize representatives of this city id enter upon the PERMIT ISSUANCEr above-mentioned property, for inspection purposes. - (We) agree to save, indemnify and keep harmless the City of Cupertino against ALTER OR ADI] TO MECH, liabilities,judgments, costs and expenses which may in any way accrue against said City in consequence of the graining of this permit. AIR HANDLING UNIT GO 10,00) CFM), APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT SOURCE REGULATIONS. AIN HANDLING UNIT (OVER 10"CFM) LOwner or authorized agent Data OFFICE PERMIINO, 29360 SANITARY NO. APPLICATION SUBMITTAL DATE '?3,-1vass6 c BUILDING PERMIT EXHAUST HOOD(W/DUCT) Sigmamre of Applicant/Comractor Date HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ((0100,000 BTU) Will the applicant or furore building occupant more or handle hazardous malarial ux defined by the Cupenino Municipal Cod,, Chapter 212, and the Health .,ad Safety Cale. Section 255321a)?' 'HEATING UNIT (OVER I W,(XM BTU) El Yes F1 No - VENTILATION BAN (SINGLE RESID) • Will the iipplictmi nr future building eccupmu use equipment or device, which emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER -COMP UIIP OR 100,003 BTU) District? " ❑Yes ON. BOILER- COMP (OVER 100,000 BTU) AIR CONDITIONER' " I have read me hazardous material, ce,m usenis mmi Chirac, 6.950 me Cali- NEW RESIDENTIAL MECH. SQ. foods Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if me building does not urrently have a tenant, that it is my responsibility to notify the occupant of the requircmentx which must forms pnnrto issuance (if. Certificate of Occupancy. P w sair .� LOwner or authorized agent Data OFFICE PERMIINO, 29360 SANITARY NO. APPLICATION SUBMITTAL DATE '?3,-1vass6 c BUILDING PERMIT 1 11 VALUATION b9 STORIES TYPE CON! MAR A 996 OCC. GROUP Al, GUTS Ur Lure nIINU BUILDING DIVISION FE PLANCHECK FEE ENERGY FEE GRADING FEE SOILg FEE ski PAID Delo Rn pt BUILDING FEE FEF. SEISMIC FEE 1 O ELECIRICFEE PLUMBING FEF, MECHANICAL FEE CONSTRUCT ION a TAX HOUSING MITIGATION PAID Date Receipt TOTA ISSUANCE DATE FEE JOB D SCRIPTION ' ❑SFDWL ❑ KITCHEN REMODEL WADDITION - ❑ PLUMBING I IPE ❑MULTIUNIT ❑STRUCTURAL , MODIFICATION ❑INTERIOR El CHIMNEY REPAIR IMPROVEMENT ZJ BATH REMODEVREPAIR (]DEMOLITION —�RESIDENTIAL: ilI - Z ❑NEW DG/ADDITION OTENA IMPROVEMENT []OTHER ❑DEMOLITION ❑ FOOD SERVICE Ott - SQ.FFT. FLOOR AREA '. $/SQ. Irl'. FEE 1 11 VALUATION b9 STORIES TYPE CON! MAR A 996 OCC. GROUP Al, GUTS Ur Lure nIINU BUILDING DIVISION FE PLANCHECK FEE ENERGY FEE GRADING FEE SOILg FEE ski PAID Delo Rn pt BUILDING FEE FEF. SEISMIC FEE 1 O ELECIRICFEE PLUMBING FEF, MECHANICAL FEE CONSTRUCT ION a TAX HOUSING MITIGATION PAID Date Receipt TOTA ISSUANCE DATE