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S 0984APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUI'ERTINO BUIhIIING - ELECTRICAL FISH' No 0 9 8 4 BUILDING DI VISION APPLICATION/I'F.RMIT ... 1huu -ME ....CAI. 11Av��jr_kry,- 1 PHONE. QQ - , ssO Sw1k{ CI;M ADD 'I�SSf P' C "ZO I hereby uffirm the, 1 nm Ilmmed under provisions of Chapter 9 (u+mmencing with Section 7000)ot Division 3nfthe Im,drssund PoceW t, Code, andmy l home is ❑KITCHEN REMOUNT. in full force and elfecl License Class Lic.# F�UU Q 6 Dam Convector ARCHITECTS DECLARATION to Z o t2Z I undersand my plate shall be used as public records CZ—Q IMPROVEMENT F" ¢I Licensed Pmfasaimal •.I OWNER.HUILDER DECLARNI'ION p, Q �(� d U 3 1 hereby ntfirm that 1 am exempt from the Contractor's License Law for the following reamn. (Section 7031.5, Business and Profesvinns Coda Any city or county W �LL0 which requires a permit Ire construe,, ober, improve, demolish, or repair anyztruclure prior toits issuance, also requires the applicant for such Permit o file a signed statement ythat he is licensed pursuant o the provisions of the Contractors License I.e. (Chapter 9 6C) A (commencing with Section 9010) of Di vision 3 of the Business and Professions Code)or d q�q that be Is exempt Ilmrefrom trod the histo for be alleged emmption. Any violwlom of NSection 9031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than Five hundred dollars ($50M). ESC ❑I, as owner of the property, or my employees with wages as their sole compensation. eg F. will notice work. oadthe structure is not intended or olTcred for side (So,. 1100E Business W and Professions Cole: The Contractor's License Law class no, avPIY to an owner of GJC. pro , perty who builds or improves theme and who does such work himself or through his .,it employees, provided that such improvements arc not armored or ofi'cred for sale. If, however, the building or improvement is sold within one yetn of completion, the owner builder will have the burden at proving that he did not build or improve for pur- pnu of sale.). ❑ 1, as owner of the property am exdmively contracting with licensed contractors to construct the pmjec, (Sec. 70pt, Business ad Professions Code:)'Me Contractor s Li- ns00 cee Law does not apply to owner property who huilds or improves mercom and QTY who commas for such products with amm,ractors) licensed pursuent of he Contractors Liceme Law. ❑ I am emmpt under Sec. ,B& P C for Ibis reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ Ihave and will maintain a Cenificam of consent oself-insure for Worker's Compen- 2 salon, as prnvided for by Section 3900 of the LeMu C(ale, for tho perf n man. of ,he work for which this permit is issued. Fj 1 have and will maintain Workers Compensation Insurance, as required by Section 3100 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carrier: Policy No.: CERTIFICATE OF 17XEMKION FROM WORKERS' COMPENSATION INSURANCE ' (Thki,coinn roodami be completed if thepennil is form a hundral dodans (E 1110) or less.) 1 sonify that in the performance ofthe work fnrwhich Ibis permit is issued, I shall not employ any person in any manner so as to bemtn, subject ,o the Wmi eri Compen- ,$ sation Laws of California. Date s O Applicant NOTICE TO APPLICANT. If, Her making Has Carl Guts of Exemption, yon should a[' become subject Io the Worker's Compensation provisions of the Labor Cole, you nest Yi Iti Q forthwith comply with such provisions or this permit shall he deemed revoked. CONSTRUCTION LENDING AGENCY U O agency ixsammee.30lending agency fnrthe perfannnnce of Ihereby ahthis the work for which this permit is issued (See. 3091, Co. C.1 permit Lender's Name OU Lender's Address D.1 1 certify that 1 have read his fDdica,ico nod true that the abase inlimmunion is V�1 coner l agree to comply with all city and county ordinances and stile laws b ing to QTY. L) z building construction. andhereby ambonurepresentatives ofthis ci,yu+ enter uqm the above-mentioned property for inspection purposes (We) ag...... e, indemnify and keep harmless the City of Cupertino against liabilities, judgmenev, cost and expenses voch rmy in any way secure i gnium said City cousegncnm or the gaming of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Z SOURCE REGULATIONS. Signature of Applicont/Conmaao, Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future huilding occupern store (ir handle hezunlou.v namrial us defined by the Cupertino Mmucipnl Code, Chapter 9.12, and ,he Health and Safety Code, Section 25532(0)? C] Yes ❑Nn' Will the applicant or future building occupant use equipment or devices which emit hamedous air contaminants as defined by the Ray Area Air Quality Management District? ❑Yes [:1 No 1 have read ,he haaardous materials regotremerd, under Chapter 6,95 of the Cali- fornia Health & Safety Code, Sections 25505, 25533 and 25531. I understand that if the building docs not comedy have a tenant, that i, is my responsibility Is, notify the occupant of,he rquimments which mus, he met prior to issuance of a Certificate of occupancy. Pecs Paid by ELECTRIC PERMIT PHRMl'1ISSUANCE APPLIANCES — RESIDENTIAL PANELS UlIT02MAMPS a I/V171 pl 1 B (Initial) FEE SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEIAR METER Olt POLE INST. POWER DEVICES SWIMMING POOL VIdic"RIC OU'ILEI'S —W S ITCI IES — FIXTURES NEW RCSIDF.NTIAI. I.I,EUR SQ [if PLUMBING PERMIT PFRMI'I ISSUANCE: ALTER—D AIN&VENT—WATER IFA) RACK FLO I[Cr. DEVICE DRAINS — F OOP, AREA, GOND. PI XTU RES—PER GAS — FA. SYST In;;- fis GAS —1?A. SYSTEM O' . S(BA) G R EAS&ENDUSTR. WASTE INTERCEPTOR GItEASETRAP SEWER —SANITARY —STORM EA. 200 FI'. WAFER HEATER W/VENI'IELECI'R WA'I HR SYSTEM)f HEATING WATER SERVICE NEW RF_SIDENI'IAE. PLMB. SQ, FT. MECHANICAL PERMIT PERMIT ISSUANCE ALIHk OR ADD TO MIKE, / AIR HANDLING ONEf(riO HII00)CPM) / AIR I IANDLING UNIT (OVER Ek" CPM) EX I IAUST HOOD (W/DUCT) IIEA'f INO UNIT (TO I00, MMI BTU) I IIiA'1'INO UNIT (OVER W,000 BTU) VENfILA11ON FAN (SINGLE RFSID) HOH.ER—COMP(3HPOR I00,OOOBTU) BOILFR—COMP (OVIiR 100,0(i AIR CONDITIONER NEW RESIDENT [A], MIiCH. SQ. far OFFICE k I It NIC CONTROL# BUILDING PIiRMIT INFO I±LOrI e PLUMB93'91 JOB DESCRIPTION RES]DI'.NTIAL, ❑SFDWI, ❑KITCHEN REMOUNT. ❑ADDITION ❑ PLUMBING RI%Pll'E ❑MULFI-UNI'T ❑STRUCTURAL BUILDIN FEE • © U' O MODIFICATION ❑INTERIOR ❑ CHIMNEY RI7PAIR IMPROVEMENT ElSWIMMING TOOLS ❑ FINITE RIiMODEUREPAIR ❑DEMOLF1[ON ❑ OTHER CONSTRI 'ION TAX COMMERCIAL ❑ NEW BLDG/ADDITION E3 DEMOLITION TENANI' ❑FOODSERVICE MPROVEMENT ❑ OTI IFR SQ, FI'. FLOOR AREA S/SQ. b FEF. / VALUATION STORIES 'I'YPECONS'I'RD OCC. CROUP APN ll DING DIVISION PEES Dam Receipt# --7L O # O BUILDIN FEE • © U' O FFH SEISMIC IT f I r W ELECTRIC FEE O PLUMBING F( (0 'res �y2� MECHAJ FEE s O CONSTRI 'ION TAX HOUSE MET IGATION FEE PAID arc Rei ciptM I 10 EA . ISSUANCE DATE � 2- 3 o --q 7 ISSUED BY: LR) if • _70 C /