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B 0104APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - BLECT$ RUILDINGDIVISION APPLICATION/PERMIT PLUMB NG - MECIIA ..as svvx_ online", ureas I re, Cf: •— [PLO" IGGTa/-d J{ygl�l► R96- Zgool ❑ Consultant Fees Paid By Applicant (Initial) LICRNSED CONTRACTOR'S DECLARATION QTY 1 hereby affirm that I am licensee under pmvisi er of Chapter 9 (commencing QWaZ with Section7(Xp)of❑ivisionJnf the Hinmessiend ProfaoionsCede,mns der,icee is Feu— in full fmrceand effect. GU U License ClassLic, # E Z W Date Contractor ARCHITECT'S DECLARATION Z FO h Z I understand my plans shall he used m public records OZ-- F sN., W Licensed Promounnal OWNER -BUILDER DECLARATION �a CC W 6 I hereby Minor that I am exempt Irom the Contractor's License Law for the O Iy U following reams. (Section 7031.5. Business and Padcssiens Cada, Any city or county which requires a lwrmil to construct, alter, improve, demolish, or repair any structure ! prlorm its Issuance, also nature, rho .... .brain for such peon to Nen signed statement Q�that he is licensed pocaumno l he provisionsnl the conaualor's License Law (Chapter 9 (vnnmencing with Seaitut 700) al Di mon Sof the Bmine,sand Profession, Core) or tiy o K that he is exempt fiarml ran and (lie hums for the Nlegcd excmpinn. Any violation of iC m 4�i See t 703 .5 by any applicant for a penal subjects thenpplicaut m a civil penalty of 4411 not mom than rive hundrul dulia, f$5IXp. .F.SC [-1I, usownerol'the property,lir it empinyces with wuges as their sole compensation, F will dm the work, and the structure is not intended Or offered Anode (Site 7044, Business and Professions Code 'I Contmona's License Low does not apply to an owner lir a 3.. property who builds lir improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. IL hmvever, the building or improvement is sold within one year of completion, the nwmrhmilder will Imve the hurcen of proving that he did an build m improve for pur- pose of sale.). 1, as owner of the pm sai,, am exclusively contracting with licensed contractors to romtrum the pore a (Sea 711W, Business and Professions Cale:) The Contractors Li- cense Law dors not apply to an mann of proper who builds or improves thereon, and QTY. who contracts for such projects with a comwam(s) licensed pursuant to the Contractors 4Lea few am as Nuce . ,B& P C for this reason own m El WORKER'S COMPENSATION DECLARATION . I hereby aNm runder penalty of pedury one of the following declmallnn$: I hove and will maintain a Cenificam of Comem to self -insure for Workers Compen- sitinn, as Provided for by Section 3700 of the Latin, Cede, for the pert arrem a of the work fm which this cre it is issued. 1 have and will maintain Worker's Compensation Insurance, as mamma by Section 7700 of the Labor Cafe, for the performance of the work for which this Permit is issued. My Worker's Compensation Insurance currier and Policy number arc: Carrier. Policy No,: CEO I FICATE OF HXEMPI'ION FROM WORKERS' COPHNSATION INSURANCE Cl hi, a action neinn IbeI olluted ethe permit is be use hundred dollars ($1flap Or leas.) I unify than in the perlormance pram work Iia which oris permit is issueq I Anna not a loy any person many nmnner.m as m heaumc subject m tbu Workcri Compeo- O%. notion Laws lir Califoro in Dam 7 Applicant 1 F7 r~A NOTIC11,0APPLICANi':If, after making Ibis Cenilicate of Exemption, you should a h her mm atiml It, the Worker's Cnmpcnsmlon provisions of the Lana Cody you must ITA G fonhwithmmplywilh suchpmvixionx mthii ambit shall bedeemcd revoked. ID z 0 CONSTRUCTION i r e..... LENDING AGENCY Li Therebyich his inhere isanu¢Sce.3nlending agency for the performance of 0 rhe eaders lir which this permit is issued (Sea Jl197, Co. C.) U Lenders Name i LcWcr'1 Address Ln 1 unify that 1 have mad thir.11 ty and county state that the above information is Z bunking loasta and withyandy and rountymdfives owns smm lawsrclaim,uom QTY U,Z building conswninn, and heathy authnma represenlativcs of thiscitym eater upon the "-' above mentioned pmpeny for inspection purposes. (We) agree On save, indemnify and keep homtlow the City of Cupertino against liabilities,judgmems, costs and expenses which may in any way accrue against said City ID consequence of the granting Of this it. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NDN -POINT SOURCE REGULATIONS. Signature of ApplicantlContr cmr Due HAZARDOUS MATERIALS DISCLOSURE Will the applicant lir future building rccnp int store or handle hmuNous material as defined by the Cuparion Municipal Code, Chanel 9.12, and the Health and Safety CWC, Section 25532(x)? ❑Yes Fl No Will the applicant or future building Occupant use equipment or devices which ,,brit hazardous air contaminants m defined by the Bay Area Air Quality Management District? ❑Yes ❑Nn 1 have rend the hmomhint mnteritds be,ancmems under Chopmr 6.95 of the Cali- fomia Ileallh & Safety Code, Sections 2550.5, 2.5573 and 25534. 1 understand that if the hailding docs not currently have O (errant, that v is my mapomibil ily to unity the Occupant of the nquircmenta which now h: sect prior to Issuance of o Ccrtiricam of occupancy. Owner lir antandled agent Data ELECTRIC PERM I PERMIT ISSUANCE APPLIANCES - REsfawr1A1. PANELS UPT02MAMPS OVER UKOAMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. 'D?ME smm HE OR POI.H INS'1'. POWER DEVICES SWIMMING POOL, IeLIiCTRIC OUTLIiTS - S W ITCHt-S - PIXi'U R I iS NEW RESIDENTIAL IiLIiCfR SQf .. SQ.FT.RLOORAREA $/SQ. lel'. PLUMBING PERMIT PERMII'NO 90104 .5�� 1 SANITARY NO. APPLICATION SUIIMI'TIAL DATI rRy ALTER - DRAIN & VENT- WATER (EA) NIC CONTROL BACK FLOW PROTECT. DEVICE BUILDING PERMIT INFO BLDG ELECT PLUMB NIEClf ❑ ❑ ❑ TYPECONS'. AIR PEE JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑KITCHENREMODLI. ❑ADDITION ❑PLUMBINGRE-PIPE El MULTI -UNIT El STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT E]SWIMMING POOLS ❑ BATH REMODEUREPAIR ❑DEMOLITION ❑ OTHER GAS - EA. SYSiTM-OVER 4 (EA) GREASE/INDOSTRI, WASTE IN * BUILDING DIVISIfIN ITiIi$ GREASHTRAP PLANCHECK FEE COMMERCIAL: El NEW BLDG/ADDITION ❑DEMOLITION ❑TENANT ❑FOOD S17RVICEI IMPROVEMENT ❑ OTHER ENERGY FEE OUTLIiTS - S W ITCHt-S - PIXi'U R I iS NEW RESIDENTIAL IiLIiCfR SQf .. SQ.FT.RLOORAREA $/SQ. lel'. PLUMBING PERMIT FEE PERMIT ISSUANCE ALTER - DRAIN & VENT- WATER (EA) VALUATION BACK FLOW PROTECT. DEVICE DRAINS- FLOOR, BOOR A R EA, COND. STORIES OCC. GROUP TYPECONS'. AIR FIXTURES-PERTRAP OAS - EA. SYSTE M -I INC. 4 OUTLEOS GAS - EA. SYSiTM-OVER 4 (EA) GREASE/INDOSTRI, WASTE IN * BUILDING DIVISIfIN ITiIi$ GREASHTRAP PLANCHECK FEE SEWER -SANITARY-STO 211;) ENERGY FEE WATERHHATf?It W/VHN'T/Ti1.I.C'rR GRADING FEE WATER SYSTEM/IItIiA'I [�.11 I U, v SOILS FEE WATER SERVICE PAID NEW RESIDENTIAAl. PLMB. SQ PT Date Receipt# TOTAL: IDTA1.: BUILDING FEE SEISMIC FEE MECHANICAL PERMIT FEE PERMIT ISSUANCE ELECTRIC FEE ALTER OR ADD TO MECH. PLUMBING FEE AIR HANDLING UNIT (TO I0k000 CFM) MECHANICALPEE AIR HANDLING UNIT (OVER 10.000 CFM) CONSTRUCTION TAX EXHAUST HOOD (W/IIUCD HOUSING MITIGATION FEE HEATING UNIT (TO 100.0X10 BTU) HEATING UNIT(OVER 1(10.000 RTU) PAIDD -- VENTILATION CAN (SINGLE RISID) ate Receipt) BOILER- COME (311P OR 100,000 BTU) T'OI'A I BOILER - COMP (OVER 100,000 BTU) AIR CONDITIONER ISSUANCE DATE ISSUED BY: / YI (UU/ NEW RESOHNUALMECH. SQ. FT. IGTAL: OFFICE