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30932APPLICANT TO. FILL IN INFORMATION WITHIN RED LINES -USE BALL CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT Xaavti{E' RCHITECr/ENGINEER: CONTACT: I hemAy affirm that I am licensed under provisions of Chapter 9 (commencing N Section ]000) c f Division 3 ofmc Business and Professions Code, add my license is full furca and effect. ase Class - - Lic, p rte Commmnr ARCHITECTS DECLARATION 1 understand my plans shell be used as public records PEN ONLY ❑ Consultant Fees Paid by Applicant (Initial) ayyx OWNER -BUILDER DECLARATION 1 brachLicense - - 0.' a y affirmthin 1 an exempt from the Cianuclorx LicenseLaw for the W 3 6 U folbwing moxa... (Section 7031.5. Business and Professions Codc: Any city or county tY a, which requires a pdrmit to construct alcor. improve, demolish, or repair any swcwm' �y prior to its issuaace, also requires the applicant for such permit o Vile a signed statement y that he is licensed pursuant to the provisions of the Commnors License Low (Chapter 9 fy Q�q (commencing with Section 71X09o'Division 3 oflhe Business and Professions Curator' d qo W that he is exempt Nerefronl and the basis far the alleged exemption. Any violation of h Section 7031.5 by any upplicant for a permit subjects the applicant m a civil penally of H z N not mote than five hundred dollars (3500). G1] Set 1, as owner of the progeny, or my employas with wages as their sole cnmpensatiaq will do the work, and restrainer, is ad, intended or offered formic (Sec. 7044, Business 3 $ and ProfeWons Cada The Contractors License Law does nal apply nm an owner of LLLLLLLt, Property who builds or improves thereon, and who does such work himself or through his own employees, provided! that such improvements arc not intended or offered for sal, if, however, the building or improvement is sold within one year of mmpleion, the owner -builder will have the burden of pausing that he did nal build or improve for pur- pose of sale.). ❑ 1, as owner of die property, am exclusively contracting with licensed contractors to construct Ne project (Sec. 7044, Business and Professions Code:) The Contractors Li- cense Law does not apply to an owner of property who builds or improves (hereon, and QTY, who contracts for such projects with a connotations) licensed pursuant to the Conimadons License Law. ❑ 1 am exempt under Sec. B & PIC for this reason Owner Dom WORKER'S COMPENSATION DECLARATION • I hereby of item under penaly of Perjury one of me following declarations: ❑ I have and will maintain a Certificate ofConxentto self-made for Worker', Co.,.-. sation, as provided for by Section 37W of the Labor Code, for the performance of the work far which this permit is issued. Khave and will maintain Worker's Compensalion Insurance, as required by Section rime Labor Cale, for the performance of the work for which this permit is issued. My Work fs C'in as in nso ce ca�ici and Policy' Cartier:(5-�I-.r�{}.Ij• cy No.: G.g` • CERTIFICATE OF EM ON FROM WOKKER COMPENSATIO INSURANCE ('This section need nm be wmpincd if Ihepermit is bnone hundred dollarn (SIM) odes.) 1 certify that in the perf intra a ,of the work for which this permit is issued, l shall not employ any person in any manner so as as become subjectto the Workers.'Compen- Oz action Laws of California. Data 0 Applicant NOTICE TO APPLICANT If, after making this Cenifcare of Exemplum, yon should 4 a , become subject m the Workers Compensation Provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall he deemed revoked. Z CONSTRUCTION LENDING AGENCY U 0 Ihcrtby affirm that them is a conalmelion lending agency for the performance of IL F the work fur which this permit is issued (Sec. 3097, Ci, CJ U Leaders Name Lal Lenders Address L� 0.1 minify that I have read this application and state thin he above information is �^ h ca sect. I agree to Comply with oil city and county ordinances and state laws relofl, to QTY, U Z building codarboaon, and herchy authorize representatives of this city to We above -marooned Progeny fill inspersion purposes. (We) agree to save, indemnify add keep harmless the City of Cupenind against liabilities, judgments, costs and rxpenses which may in any way accroe against said City in cousquence of me granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT SOURCE REGULATIONS. Signature of ApplicadnConuamor Dae HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building nconpant store or handle hazardous nmterial as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health anti Safety Code Section 25532(a)p El Yes Ohio Will the applicant or future building occupant use equipment or devices which emit haznrdou.s air contaminants as defined by the Bay Area Air Quality Management District? I , I] Ycx ❑ No 1 have"mend the huzurdnus materials requirements under Chapter 6.95 of the Culi- fomia Health & Safety Chair, Sections 25505, 25533 and 25534. 1 understand that if the building does not currently have a tenant, that ii is my resporeihil by to notify the occupant of the no irtmentx which runts met prior to issuance ofa Cenifcute of Occupancy. ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - kESIDEN'1'IAL PANELS UPT02MAMPS SIGNS ELECTRICAL - SPECIAL CIRCUIT/MISC. TEMP. METIER OR POLE INS'1'. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - LIST 'URES NEW RESIDENTIAL ELECTR SQ PP. PLUMBING PERMIT PERMIT ISSUANCE ALTER - DRAIN & VENT- WATER (CAL ]LACK FLOW PROTECT. DEVICE DRAINS- FLOOR, ROOF, AREA, COND. FIXTURES - PER TRAP GAS -EA. SYSTEM -1 INC.4 OUTLETS GAS -EA SYSTEM -OVER 4 (EA) GREASE/INDUS'1'BE WASTE INTERCEPTOR GREASETRAP SEWER -SANITARY -STORM F.A. 200 FT. WATER DEAL FR WNENT/ELECTR WATER SYSTEMI`FREATING WATER SERVICE NEW RESIDENTIAL FEAR SQ. FI' MECHANICAL. PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT LT. IIkINNI CPM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) I(HATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RCS ID) HOILER-COMP(9HPORILE,nMITU ' BOILER - COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. TOTAL. OFFICE 30932 'NO. APPLICATION SUBMITTAL DATE �7 (.'1 CONTROL# BUILDING PERMIT INFO SQ. FT. FLOOR AREA 5/SQ. IT. PAID N 16 RECI Y Ut UUrtH I1N0 VALUATION STORIES TYPE CONSTRUCTION (ICC. GROUP APN BUILDING DIVISION 11131iS PLANCHECK FEE ENERGY FEE GRADING FEE r SOILS FEE PAID Date Receipt# TOTAL.: BUILDING FEE FEE SEISMIC THE ELECTRIC FEE PLUMBING FEE' MECHANICAL FEE CONSTRUCTIONTAX HOUSING MITIGATION FEE PAID GamReceipt# TOTAL: ❑ FEE JOB DESCRIPTION RESIDENTIAL ❑SFDWL. ❑ KITCHEN REMODEL ❑ADDITION- ❑PLUMBING RE-PIPH ❑MUI.TI.UNIT El STRUCTURAL MODIFICATION 13 INTERIOR ❑CHIMNEY REPAIR - IMPROVEMENT ❑ BATH REMODEL/REPAIR ❑ DEMOLITION ❑ OTHER L COMMERCIAL' ❑NEW BLDG/ADDITION ]DEMOL.ITION ' ❑TENANT ❑ FOOD SERVICE IMPROVEMENT' ❑ OTHER SQ. FT. FLOOR AREA 5/SQ. IT. PAID N 16 RECI Y Ut UUrtH I1N0 VALUATION STORIES TYPE CONSTRUCTION (ICC. GROUP APN BUILDING DIVISION 11131iS PLANCHECK FEE ENERGY FEE GRADING FEE r SOILS FEE PAID Date Receipt# TOTAL.: BUILDING FEE FEE SEISMIC THE ELECTRIC FEE PLUMBING FEE' MECHANICAL FEE CONSTRUCTIONTAX HOUSING MITIGATION FEE PAID GamReceipt# TOTAL: