S 2094APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - VSE BALL POINT PEN ONLY
CITY OF CUPERT'INO BUILDING - ELEC I N
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECUA
BUILDING PROJECT (DEN
BUILDING ADDRESS:
.21807- f} LI4,06AI c iRRCCCE ( 41'FA/u Z-)
Shl[BEi2T YouAPG & FhfIMRI [C nd�!p CONTRACf(1R'S NAME:
Aceeet yoµgiJG 40s- 14z -o4sjT
LICENSED CONTRACTOR'S DECI.A RATION
I hereby ullinn thin 1 um titmice mot r pmvisiunv of Chupmr 9 (conurmmeng
with Section 7000) of Division 3oflhe lbromessand Po lions Code, and lay license In
in full force and eRect.
l'ine'd Class Lic.#
Date Contractor
ARCHITECTS DECLARATION
i understand my plans shall he used as public records
❑ Consultant Fees Paid by Applicant (Initial)
OWNER - BUILDER DECLARATION
I hereby nflirm Our I nn entpn fi'ou1 the Convamor's License Law for the
following reason. (Section 700 I.S. nosiness and PmRsslons Code: Any City or county
whim requires a Permit lv construct. alter, improve, demolish, or repdr any grveture
prior In its issuance, also requires the appliam lira such permit o the a signed shaemenl
(hat he is licensed pursuant me the provisions arise Contractor's I.meme Law (Chapter 9
(eomnonctng with Section Wa of Division 3 ofthe Business and Professions Code)nr
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Seen 1703 L5 by ,cry .,,,I rd Lora pemnt mbject.s the "'Pliant to it eir"I Penally or
not mare than Bve hundred unit. ($5001
❑ I, as owner of the property, or my employees with wage% as their sole compensation,
will do the work, Itnd thesaucmre is not intended oroffered fors :da (Sec. 70ol Biomes
and Profnsions Code The Conlrn Un, License Law does not apply to an owner of
progeny who build. or improves thereon, po who aces sock work himself onhroagh
his own employeese hurldir, that such improvements are not intended or or offered for
sale. II; hnweven the have thng or en of proving is sale within one build or improve for. ate
ow , mf' ,e). will have the burden of'hieing (hat he did not huilJ or improve for pnr-
pose of linen).
r the Pnepeny, rim exclusively Protrueling with :) The conlmmnra io
tfua the es net (Sea. t) an Business and ity who bui ds or rupro es them., and
whocatawdmsnsuch plyman owner of pmpeny whosedpnr improves thereogors QTy
who cataracts for such projects with n mnmomnr(s) liwrvsul pursuit w me Contractors
License Low.
❑ I VResem m
N under Sec. _,B &PC hhis reason
.l /Y. A-AI SIX
WORKER 'S MI'ENSATRIN DCLARATION
I hereby affirm under pC Iryof perjury one of the following declaretiom:
❑ I havelmd will mointain uI Cenificaterf Consent tralh'orsurebrWnrkm'sCompen-
aatinn, us provided for by Section 3700 of the Luber Code, for the performance of the
work far which this Perri in is issued.
❑ I hoe and will comma in Wmko's Compensation loo rule, us required by Section
9900 it the Labor Code. for the perfunica ce al'the work for which Ibis perma is issued,
My Workers Compensation Dramatic carrier and Policy number are:
Carver: Policy No.:
CH BE IFICA'I'E Op 1 I EMP'I ION FROM WOE K Ii RS'
COMPENSATION INSURANCE.
('(his section need not be cmadcled if the p,no, is forone hundred dollar (51011
or less.)
I certify Thal in the pclbnnace, of the work for which lhia permit is'PSatd, l shall
not employ any person in any manner so as to Mcome subject to the Workers' Compen-
scion Laws of Cali romia. Dole
APplic I I
NO) ICE TO APPUCANn If, after making this Certificate of E,r mptiun, you should
became stag l to the Worker's Compensation provisions of the Labor Cade, you most
camwalt nmtply with such pn vio t ar (his Permit shall be demnM rooked.
CONSTRUCTION LENDING AGENCY
1 hereby option than mere is a conduction mnding agency for the performance of
the work for which (his permit is issued (Sec. 3099, Cie. CJ
finders Name
Lenders Address
I certify teal 1 hove mat this applicutln t and .talc that the above out arnmlion is
correct. I agree to comply with all city and county ordinances and state haws miming to QTY.
building construction, and hereby alnhnnrgrepreumativesafthis en meme'tri
above. Inenbnned Pmpeny far impectian Pui - - �
(We) agree m save, indemnify and
�eepry.191 me+ Uy W;Cm_penino ag. ins
liabilitics.judgmenu, cols anJ expensci�fbTh.yy�fnI _ al) we5— `.'vYS1.I Ci
in conseuluence or the gunning of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON - POINT
SOURC%ULAT10NS.
HAZARDOUS MATERIALS DISCLOSURE
Will the appllanl nr luwre M1uilAing nal,pnnl stern or boodle hazarcluns mmeriul
as el lined by the Cupertino Municlpul Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532mC
❑ Yes c{S
Will the applicant nr far.. building accup., use cquipmnn or devices which
emir hazardous air comm rcia 1. us defined by the Bay Area Air Quality Management
Diatricl'!
p Yes W- ,
I hive sad the hanmlous materials regniuements under Chapter 6.95 (it the Cal l -
h mie Ihealth & Sorely Collor Sections 25505, 25533 and 25534.1 understood Thal if the
building clue, nor currently Itasca mtmnl, that it is my resPowislily to notify the occupin
of the nit wI econts which mast Iw mTdgyor to issuance of a Certificate of Occupants.
ELECTRIC PERMIT
FERMI r ISSUANCE
APPLIANCES - IIHSIDEN'I'IAL
PANELS
UP TO 200 AMPS
OVER 100 AMPS
SIGNS ELECT ICAL
SPECIAL CIRCUIT' /M ISC.
FEE
F v
PLUMBING PERMIT i FEF,
PERM jr, ISSUANCES _
ER -DRAIN & VENT- WATER (HA)
BA (llV FROTF.CT. DEVICIi
GAS -
GAS -
WATT7R []LATER WNEN'I /ELECTR
WATER SYSTLMUEEA'1'ING
WAT17R SERVICE
NEW RE.SIDENOAL PLMB. SQ IT
MECHANICAL PERMIT II FEF.
PERM I']' ISSUANCE J �.
ALTER OR ADD TO MI CH.
AIR HANDLING UNIT fl10 IB,,, CFM)
AIR HANDLING UNIT(DYER 10,110 GPM)
IiXHAUST HOOD (WNUCT)
HEATING UNIT (TD 100,0110 BT'Ip
HEATING UNIT(OVER fful BUD
VENTILATION FAN (SINGLE RHSID)
BOILER - COMP (3HP OR 100,000 BTU)
BOILER -COMP (OVER 101,000 It I'U)
AIR CONDITIONER
NEW RESIDEN'I']AL MLCIL SQ. FT
OFFICE
2094
NIC CONTROL#
° 7g7`_�
6� Cfi- a— 19—
JOB DESCRIPTION
RESIDENTIAL:
❑SFD 1.
ID KITCHEN REMODEL
7DI'1'ION
11 PLUMBING RE- PIP('.
❑MULTIUNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ SWIMMING I'OOIti
❑ BATH REMODEUREPAIR El DEMOLITION
❑ uTHER
COMMERCIAL:
[]NEW BLDG /ADDITION ❑DEMOLIT(ON
J&ENAN'P, 1:1 FOOD SERVICE
g1 SQ, 17. FLOO
I /
Z /7) D o�
1H:C.G l Ul' �''IN /
GRADIN ,FEE
SOILS Ii
PAID
Date Receipt#
TOT :
111111. GI'EE Q
SL FEE
I. IC FI'.E
'LU BING FEE
M TIANICAL THE
C( NSTRUCHON TAX
II (SING ME I- IGA'1'ION FLIT
PAID
])am Bee #
T ..
ISSUANCE DATE.
31�(T ?y