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27553APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-- KI'KCI RI A. PERMITNO, APPLICATION/PERMIT PLUMBING -ME011ANICAI, n 7 C C 3 BUILDING DIVISION BUILDING PROJECT ]DEN I IFICA'I'ION . G J tJ © 33 o S'P2 .X -.x r." It ttv,T. 1 Au�IIITECT/FNGINEER: LIC NO: ADDRESS: 1-htuGa� "Cd CIA .7'-t Sas LEA. ICONI'ACT: PHONE: LICENSED CONTRACTOR'S DECLARATION I h m byarfimt thm l am licenxdunderpmvisionsofaapmr9(cormnencing with Section 70(10) of Division 3 of the Business and Professions Cam, and my liters, is in full force and effect. I nse iceCla s Liu. p Dam CantracmI ARCHITECTS DECLARATION I undersumd my plem shall be mad us public records. Licensed Professional OWNER -BUILDER DECLARATION I hereby mfor n that 1 am campin frau the Commerce's License Law for the following reuson. (Seaton 7031.5, Business and Professions Code; Any city or county which nefores a permit to compact, after. improve, demolish, or repair any structure priono its issuance. Mso requires nexpplicant for such permiun file a signed statement that he is licensed pursuant to the provisions of the Cotnmaor's License Law (Chapter 9 (commencing with Section ]000) of Division 3 of the Business and Professions Code) or thus he is exempt therefrom and the basis for the ullcged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner ofthe property, ormy employees with wages as their sole compemmion, will do the work,:md the structure is not mendedortdfmcd for sale (Sec.9tk14, Business and Profusions Code: The Contractors License law does not apply to at owner of property who buildsorimproves barren, andwhodoesxchwork hitmelfornrnughhis own employees, provided that such improvements am not intended or offered forads. If, however, the hu Iding, or improvement is sold within one you afrompirtion. the owner- builder wever,thehulldingorimprovementissoldwithinoneyamafcnmpletiondheowner- builder will have the burden of pmving that he did not build or improve for purpose of sole.). ❑ (,"owner of the propeny, amexclusively contracting with licensed contractors to corstmct the project (Sec. 70al Business and Professions CnleO The Contractor's License Law docs not apply to an owner of morst who builds orimmovesthere se. andl License Law. ❑ 1 um exempt under Sec. , B & P C for this m Owner Dem -•covers WORKMAN COMPENSATIONDd a. adf TION ❑ Iherebyaffinn thatlhuveecenificem of conxm mxlf..ho..orac tifcate of Workers' Comlmnsmion Insurance or a certified copy thereof(See. 3g W, C.)which MI employee's under this permit. Polley # ❑ Candler! copy is hereby furnished. XCcti Red copy is Bled win be city impeutlon divido CERTIFICATE OF EXEMPTION FR WORKERS' COMPENSATION MS NCC (This semina need nes be completed ifs resit is for onehwd all or less.) Icmify that in rte perfonnance of new kfor which nix permit hell nm employ any person is any, m to been. sabjafvt su orkers z Compensation Laws of Califomia. Date so Applicant XX �O NOTICE TO APPLICANIT:If, after making this Ce 'icaaMExempricn, you paid I -'I f/) become subjceno the Work<rs Compensation provisia ofthe Lahr Code,ye, must forthwith comply with such pmvisiom or this permit shall deemed revoked. ow �] CONSTRUCTION LENDING AGENC D z I herebyaffirm door hem iso cam action Imulingagenc�f.,ormamesif U O the workfar vad c ape is issual (Sec. 3097, Civ. C.) Lender's Name O L.I I.atder's Address I certify that I have read this application and state that the abpve in etion is i' a correct Iagree meomply with all cityand cowryoNimnoesandsmelaws sings rF-t buildingeonshruction, and hereby authorize representatives ofthis city to ester up, e U Z above-mentioned property for inspection purposes. �7 (We) agree to save, indemnify and keep h "pleas the City of Cupertino against liabilities,judgments, costs and expenses which may in any way seems against said City in cs�n�k�nceoflryegram gof tis permit. - / C D ,J L_ijV 1 G/ 1 /_9 Signaore of Applicam/Contre cool Dae HAZARDOUS MAIERIAIS DISCLOSURE Will the applicpa or more building occupant smro or handle hazardous material as defined by the Cupertino Municipal Coda Chapter 9.12, and the IleMth and Safety Code, Section 25532(a)? ❑ Yas INN. Will the applicant or fuwm building occupant use equipment ordevices which emit • hazalloos air contaminenb es defined by the Bay Ame Air Quality Management District? ❑ Yes 1 have read the hairpieces mammals requirements under Chapter 6.95 of the Califomia I l.Ith & Safety Coda Semiom 25505, 25533 and 25534. 1 understmtd that if the building does not currently have a tenant, that it is my responsibility to notify the cv�4of the ted iremAA which mart be met prior to Issuance of a Clproricate of agent PERMIT ISSUANCE. APPLIANCES - RESIDENTIAL PANELS UP TO 200 AMPS SIGNS ELECTRICAL SPECIAL CIRCUITMISC. TEMP. METER OR POLE MST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES a NEW RESIDENTIAL ELECIR _SQ. FT. PLUMBING PERMIT PERMIT I..UANCE ALTER -DRA RVLNT-WATER(EA) BACK FLOWPR ECT. DEVICE DRAINS - FLOOR.R P, AREA, GOND. FIXTURES - PER TRAP GAS -PA. SYSTEM -I INC. U'1'LETS GAS - IM. SYSTF-OVER 4()U EA. 2n0FT NEW RIS19ENTIAL PLMR. SQ. FT. FE IEE C FEE FLOOD ZONE TOTAL: ELECTRIC FET `MECHANICAL PERMIT FEE' PLUMBING EEE PERMIT ISSUANCE MECHANICAL FEE ALTER OR ADD TO MECH. CONSTRUCTIONT X FEE SUMMARY AIR HANDLING UNIT (OVER 10,001 CPM) SID E EXHAUST HOOD(W/DUCT) SANITARY Y HPA1'ING UNIT (OVER 100,0d) BTU) p F RECTII'#_ BO11,1?R -COMP (31IP OR Iop,OU(1 BTU) SCHOOLTAX Y NEW RESIDENTIAL MECH. SQ. Pf. RECEI Tp_ PARK FHE Y REcr: r# BUILDING DIV ;ION F PLANCHECK FEE GRADING PEE SOILS FEE \ ENERGY FEF. PAID SEISMIC FTP. TOTAL: ELECTRIC FET `MECHANICAL PERMIT FEE' PLUMBING EEE PERMIT ISSUANCE MECHANICAL FEE ALTER OR ADD TO MECH. CONSTRUCTIONT X AIR HANDLING UNIT (TO 10,110) CFM) AIR HANDLING UNIT (OVER 10,001 CPM) EXHAUST HOOD(W/DUCT) PAID Dam Receipt# HEATING UNIT (TO Ed," BTU) HPA1'ING UNIT (OVER 100,0d) BTU) p F VENTILATION FAN (SINGLE RESID) BO11,1?R -COMP (31IP OR Iop,OU(1 BTU) ISSUANCE- UhTE PIA �.��T///��Da�����. DEC xL � gyi{� Y}�Jtt. UU01—�IgIT[V�uiOlf�/, ISSUED BY, BOILER- COMP(OVER 100.000 BTU) NEW RESIDENTIAL MECH. SQ. Pf. TOTAL: