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99090190APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING DIVISION APPLICATIONIPERMIT CONTACT: LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing .an Section 9(110) of Division 3 of the Bmine, and proresclo.s Code, and my hrens. is in full far,c an� LicencaC Lic.# Da¢�s Conn' A CIi11 be a DECLARATION d I M1�IIM ed us ublic records LIC NO'. ❑ Ct nsultant Elms Paid by Applicant (Initial) ELECTRIC PERMIT PERMIT ISSUANCE PANELS O0ZyeF lundentan my p anss a us p UI' T0200 AMPS � F�FW Licensed Promsomord 20L1000 AMPS R IIX0 AMP5 Win Q J ( 0'" DECLARATION m Contractor', LmimLaw f the JOB DESCRIPTION RESIDENTIAL; ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION ❑ PLUMBING RE -PIPE ❑MULTI -UNIT [I STRUCTURAL MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT (] SWIMMING POOLS ❑ BATH REMODEL/REPAIR ❑ DEMOLITION '❑'••O,,THER L4 � HF, 6I e hereby affirm that I nm exempt from Tire Code: Any roa-mi ��(' 6 ) following ream.. (Scctinn 9031.5, Business and Pmfc,,inns city SIGNS ELECTRICAL. PLANCHECK FEE 1x13 W I"' which require, a permit u, c morret, alter, impnnv, de oubdt, nr repair any suucmre � prior runt issuance.al,urequires the applicant for such permitm tile. signedstmement SPECIAL CIRCUI OMISC. Q Nat he is licensed pursuantmthe peropions of the Conmcu,rs License Law (Chapter9 POLE INST. NEW RESIDENTIAL PLMB. SQ. ET. (commencing will, Section 900spnf Doolun 3 ifthe Businevs and lrmfictoons Code)... TEMEI' ER OR that he i, exempt therefrom and the hml, for the alleged exemption. Any violation of DEVICES NSection 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER not mor, than five hundred dollars ($51X). ax owner of the prnpeny. er mY entpinyees with wage. as their sole contpcnmtie., SWIMMING POOL ELEC'[RI ZQL, will dnthe work, and the structure is not intended or offered for sale (Sec. 7044. C L 3 said frodeasionn Crile: The Contractors License Law does not apply to an owner of OlT1'LETS—SHTTCHF.S-1' 1(3 NEW RESIDENTIAL ELECTR property who builds rte improves th,mon..nd who does.vuch work himself., through IT ' h' ems arc not intended or offered for h, own employees, pruvtded t at sue I Par m s sale. IL however. the building., itnprovctnenns mid within ono year afconipldion.the owner -builder will have the burden of proving Lha he did not build or improve for put- pom of sale^e l th1propery. nor as'laorval, cominedir, sith licensed cor(ot to consumer the project (Sec. 9044 Business d Sumerians Code) The Contract r: Li- remse Laus does of ply no rosmar of poultry hit b Id. or imprmxs theomn. and Q'ry, I In, ralow,for sual, projecuwth a ennracond a) licen.-ul pununn 1. heCnntr a rs License Law. Fl I am exempt under Sec. ,B& P C for this mason Date WORKERS COMPENSATION DECLARATION I herehy i. unJV, pauaty of perjmy one of the 4illowing declnmtions'. ❑ 1 have and will maintain a Canilicae of Consent o self-insum for Worker's Compen- sation, as provided for by Section 37M of the labor Code, for the performance of the work fur which this permit is Lsaued. ❑ 1 have and will maintain Worker's Compensate. In sur once, as required by Section 39M of the faMu Code, fnr the performance ofthe work for which this permit is issued. My Worker's Cmnpemntion lmmlmnce Tinier and Policy .amber ore: Carrier: Policy hi CE.KTIIICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if tha permit is Tomos hundred dollars (S I W) or less.) 1 employ any than in lbs perl'manceroul s to be k roewlach subject his the ior ers'Co 1 shall not employ any person in any manner m as In become suhjea m the Workers' Comltcn- C Z Nation l.awfC�alifomj. ate O Applicant at• f NOTICE. TO APPLICANT: If, a ter making this Certificate of Exemption, you should [—r `N' become subject nature WnrImes Compcmaoon provisions of the Labor Cudc, you maul [. rnnhwithemnply with such provisions or this permit shin l he daunted revoked. y,G CONSTRUCTION LENDING AGENCY I herchyafirm thrn an ding is anmonalioding agency for the perfmman,v of V 2 Lks F the work for which this permit is issued (Sec. 3019, Civ, C.) O U Lenders Name �. {A Lender's Address 6. 1 cuddly that 1 have read this application had state that the ohove information is CCy correct. I agree Io comply with all city and county ordinance: end state laws relining m QTY.) Z building consoc,mr, and hereby anlbori'm repre,entafives of this city m enter urym the above mentioned property for inspection purposes. (We) agree m s: vc, indemnify and keep handless the City of Cupertino against liabilities,judlurmdp Is reWcpen... which may In any wayoccrueuguinsts.iA City to or als.,eof a gr+�y XbJ this rmre�/ e t p reopen... w1 D I,er WITH ALL NON -POINT HAZARDOUS MA9ERIALS DISCLOSURE Will the appllea d or future building occupant store or handle hazardous maerial as defined by the Capenino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(x)? ❑Yes PV.Will the applicant or future building occupant use equipment or devices which .nit no,com us air cvmunninctts as defined by the Bay Area Air Quality Management Unsaid? p Yax I have read th zardnu cr Is red under Chapter 6.95 of the Cali- m fomia Hwhh & S y C ti ns 25 2551] an 3531. L underslmtd dna if the re 7I� nnnr mi irttrne.lfteinildlhv to notify cite occammat LAWMEA q 3a^9 SQ. FT. MOOR AREA TOTAL: ILII Irs' 2 91999 PLUMBING PERMIT' PERMIT ISSUANCE. "01, i 1lr,DU1I.DINOPERMITINFO, - .r. VALUATIOD V BLDG ELECT PLUMB MF.CH DRAINS— FLOOR, ROOF, AREA, COND, R OCC. GROUP JOB DESCRIPTION RESIDENTIAL; ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION ❑ PLUMBING RE -PIPE ❑MULTI -UNIT [I STRUCTURAL MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT (] SWIMMING POOLS ❑ BATH REMODEL/REPAIR ❑ DEMOLITION '❑'••O,,THER L4 � HF, GAS— EA. SYSTEM -I INCA ODIIETS GAS —EA. SYSTEM -OVER 4 (EA) GREASUINDUSTRL WASTE IWERCEPTOR i . BUILDINGUIVISR GREASETRAP PLANCHECK FEE SEWER — SANITARY — SI ORM EA. 200 t1'. ENERGYFEE COMMERCIAL; ❑NEWBI.DG/ADDITION []DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER GRAVING FEE WATER SYSTEMaREATING SOILS FEE SQ. FT. MOOR AREA TOTAL: ILII Irs' 2 91999 PLUMBING PERMIT' PERMIT ISSUANCE. Aid 17R — DRAIN & VENT— WATEIt (EA) VALUATIOD V BACK FLOW PROTECT. DEVICE DRAINS— FLOOR, ROOF, AREA, COND, R OCC. GROUP FIX] 'URES—PER TRAP GAS— EA. SYSTEM -I INCA ODIIETS GAS —EA. SYSTEM -OVER 4 (EA) GREASUINDUSTRL WASTE IWERCEPTOR i . BUILDINGUIVISR GREASETRAP PLANCHECK FEE SEWER — SANITARY — SI ORM EA. 200 t1'. ENERGYFEE WATER HEATER W/VENT/F.LECTR GRAVING FEE WATER SYSTEMaREATING SOILS FEE WRDiR SERVICE PAID Dote k t NEW RESIDENTIAL PLMB. SQ. ET. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECI I. AIR HAN DI.ING UNIT (TO I0,0)I1 CFMI AIR HANDLING UNIT (OVER 10,000 CPM) EXUAUS'I HOODOW/DUCT) HEATING UNIT (IT) 100,100 BTU) HEATING UNIT (OVER 10.000 BTU) V EST [LAI FAN (SINGLE RESI D) BOILER —COMP (3HP OR 110,0011 BTU) BOILER — COME (OVER 100.0(10 BTU) AIR CONDI'I'IONEIZ NEW RESIDENTIAL MECH. SQ. IT TOTAL: OFFICE BUILDING 17EE FP.E' SEISMICInE171 ELECTRICFEE PLUMBING FEE MECIIANICAI. PEL CONSTRUCTION TA HOUSING MITIGATION FEE PAID Date Receipt# TOTAL: y3``oa� ISSUANCE DATE 1 30 -�f9i, ISSUED BY'.