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305460z F �Cee iRe I .:0 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY IIUILDING- ELECTRICAL PERMI'1'NO. /� O CITY OF CUPVISION APPLICATION /PERMIT PLUMBING, MECHANICAL J l••f BUILDING DIVISION n111LDING PRf3JF.CT IDF.NTIfUNIN!, 3z r LICENSED CONTRACTOR'S DECLARATION , 1 hereby affirm that 1 mat licensed under provisin s of Chapter 9 (comntcncong with Section 700H.f Division 3 ofthe Business and Professions Code, and my license is in fall force aad effect. License Class LIc# Date Contractor ARCHITECTS DECLARA'HON 1 understand my plans shall be --it as public records Tkop W. ❑ Consultant Fees Paid by Applicant (initial) OWNER - BUILDER DECLARATION 1 hereby affirm that I am exempt fmm the Contractor's License Law for the following reason. (Section 7031.5, Baroness and Professions Code: Any city or county which requires a permit to constrain, the,, improve, dam il'rsh, nr repair any structure priorto its issuance, also requires the applicant for such Permit it) rile a signed statement Nm Ira is licensed pummmt to the Provisions Of Ire Contractor's license Law [Chapter 9 (commencing wish Section 7000) of Division J of the Business and Professions CMG) or ,hat he is exempt thercfmm and the basis for,he alleged exemption. Any violation of Section 7031.5 by any applicant far t Parmi, snnJec,.a Na npplicum to a civil penalty of not mum arm five hundred dollars (S501). ❑ I, as owner ofine property, or my employees with wages as their sole compesalion, will do the work, and the stractore is not intendal oroffered for sole (Sec. 70004, Bnsinens and Professions Cole: The Comoctors License Law does not apply to an nwncr of property who builds or improves thereon, and who does such work himself or,hrotrgh his own employees, provided ,hut such improvements are am intended ar oBcred for sale. If, however, the building or improvement is sold within one yemof completion the owner- hadder will have the burden of pmving that he did not build or improve for mr- paae cf. sided. 1, a owner of the progeny, am exclusively contracting with licensed contractors to construct die project (Sec 70,14. Business end Pmfesdam Codi The Combat Li- cense Use does not apply toanownerofpmpeny who builds nrimprovc ,,heron, and QTY. who contracts for such pr.jm,a with aemarr sns) licensed pursuant to the Contractors License Law. ❑ I um exempt trader Sec. , Ii & P C for this mason ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UPTO 200 AMPS Owner Dare • WORKER'S COMPENSATION aDECLARATION I hereby illasm under pemhy of Perjury one of the following d uron', m: I have mW will mor by a Cmlficmc of the 1-a or Code. for her Wnrkerence Of the ,moon, as provided for by Section 3]101 of the Irbar CMe, hsr the pcdnmmnce of the work far which Nis permit is issued. 1 have and will mnlnmin Worker's Grmrynsatim Ismeme, ns required by Seetion 3700 of the Labor Code, for the perfmnaence of the work for which this permit is issued. My Workers Compensation Inannime cancer and Policy number are: Carrier Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section neednol be camplered ifthe Pemal is forum hundred dram's 1$ Itxq or less.) I certify that in the my nom number sit s to become for su ich,hit, the W rkissued, Conipsall not employ any person in any manner xo as In become suhjed m the Workers Cnmpen oz sation Lawsof Califnmia. Date NOTICE TO APPLICANT. IL after making this visinsofof Exemption, iox youshoolst [-+ become subja, no Ne Workers Compensation provisions of Nc Labor Ode, you most � t'7..i forthwiN comply with ouch prnvisiona or Nis permit shall he ]Gerard rcvnked. 4' z CONSTRUCTION LENDING AGENCY VO I hereby affirm that there is a concoct on lending agency for the perforoanceof the work for which this person Is issued (See 3197, Cie. C f-' J 0 p U Lenders Name � Leader's Address p fy. I certify that 1 have read this application and ,tune that the above intimidation is ra y correct. l agree to comply with all city and county ordinances and slide laws retuning to QTY <•) building cemblauirn. and bemhy amhorize rcpresmami van of this city to enter upon the abavementioned progeny for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Calton- against linbilitiee,judgmema. m >ts:E use which tasty in any wiry accme against said City in consequence of a 8mmiermit. APPLICANT U JERSTA WILL COMPLY WITH ALL NON -POINT SOURCE REGI NS. S nature of pp icam /Contractor Dam It MATERIALS DISCLOSURE Will the applicant or future building occupant snare or handle hazardous material as defined by the Cupertino Municipal Gale, Chapter 9. 12, and the Health and Safety CMG, See.. 255326d? ❑Yes ❑NO c Will the air r applicant or future building occupant use equipment or devices which mot mount the air licant r f eta as IcfmM by the tiny use a Air Quality Management Dom a? [I Yes ONo SIGNS 131.ECTRICAL SPECIAL CIRCUIT/MISC. 'TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW R13SMEN'I IAL P,LECTR PLUMBING PERMIT PERMIT ALTER -DRAIN & VENT- WATER IRA) BACK FLOW PROTECT. DEVICE DRAINS - FLOOR, ROOK AREA, COND. FIXTURES -PER TRAP GAS - EA. SYSTEM -I INC. 4 OUTLETS GAS - EA. Sys rEsd.OVER 4 (13A) GREASVINDUSTRL WASTE INTERCEPTOR ORGSE TRAP SEWER,_ SANITARY -STORM F.A. 200 17' WATER HEATER WIV M- MLECTR WATER SYSTENUORLATING WATER SERVICE ' NEW RESIDENTIAL PLMIL SQ, FT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFMI AIR HANDLING UNIT (OVER IBM) CM) EXHAUST HOOD (W /DUCT) HEATING UNIT (f0 1110,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTII.ATION BAN (SINGLE RESID) BOILER -COMP (3HP OR I DOW BTU) BOILER - COMP (OVER 100,000 BTU) i have read the hazardous nationals reNtimmcros under Chapter 695 Olt Cali - foram Health & Safety CMG, Sections 25505, M533 and 25534.1 uadersmnd thm if the NEW RESIDENTIAL MECH, building does not cranially base mmmit, that it is my rosporability to nmify the occupant of the mqulmmcnts which must her met prior to issuance of a Cenilicate of Occupaacy. Owner or au,hmired ri Date OFFICE SQ. IT. TOTAL: 11 ❑ ❑ ❑ FEE 0 JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ KITCHEN RFMODF,L ❑ADDITION El PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑INTHRIOR ❑CHIMNEY REPAIR IMPROVEMENT L;BATH REM Op���/g�{spA fp'Mp�I,gN OTIIr ar /aaF� �Ll�i- COMMERCIAL: ❑NEW BLDG /ADDITION C3 DEMOLITION ❑TENANT [I FOOD SERVICE IMPROVEMENT ❑ OTHER FEE FT. FLOOR AREA STORIES BUILDING DIVISION FEES PLANCIfECK FEE ENERGY FEE. GRADING FEE SOILS FEE PAID Date Rneelpl# TOTAL: BUILDING FEE FEE SEISMICFEE ELECTRIC FEE PLUMBING FEE I MECHANICAL, TEE I CONSTRUCTION TAX I HOUSING MITIGATION FEE PAID Date Receipt# TOTAL: 4 Ff. '