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S 1005APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY .CITY OF CUPERTINO BUILDING - ELECTRICAL Bl7fi.DING DIVISION APPLICATIONIPERMIT PLUMB NO - MECHANICAL. PERMIT NO. S 1005 BUILDING PROJECT IDENTIFICATION BUIIDINGADDRESS qp 4 SANITARY NO. APPLICATION SUBMITTAL DATE W' OWNER'S NAME: PHONE: CO TRACfO 'S NAM /�� N/C CONTROL.# ❑ ARCHITEC7VENGINEER: I.IC NO: ADD (S aID�666.ii��+++ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLDDOG/ ELECT PLUMB MECH I L ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION L hereby affirm that 1 am licensed under previsions of chapter 9 (commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION with Section 7000 of Division 3mfthe Business and Professions Code mi nylicenseis in full force and effect. / License Class LILk Date Contractor RESIDENTIAL: ❑SFDWL [IKITCHEN REMODEL []ADDITION❑PLUMBING RF. -PIPE El MULTI -UNIT ❑STRUCTURAL MODIFICATION PERMIT ISSUANCE APPLIANCES -RESIDENTIAL ARCHITECTS DECLARATfl5N I understand my plans shall be used as public records PANELS UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR IMPROVEMENT []SWIMMING POOLS ❑ BATH REMODEWREPAIR ❑ DEMOI.I ION , MOTHER - T Licensed Ptnfexannal Qat I am BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professiti Code: Any city nr county which requires a permit to construct, aper, improve, demolish, .r repair any structure 201-11"AMPS OVER I000AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. prism its iss... ce,slsorequires meappllcarr for such permit n fleasignedsmtement that he is licensed pursuant to the provisions ofthe Convectors License Law (Chapter 9 TEMP. METER OR POLE INST. COMMERCIAL: (atm ting with Sectlon7D%q of Divlslon3 of the Business and Pmfea,innn Gtde)nr that be is exempt therefrom middle basis for da alleged exemption. Any viola ion of ❑ NEW BLDG/ADDITION ❑ DEMOLITION POWER DEVICES Section 7031.5byany applicant for a permit subject, the applicatto. civil penaltyof not morethan five hundred dollar, ($500), y, or my employees with wages as their sole consmion, ❑1, as owner of the papertpen will do thework, and the stmemre is nm intended nr.Acted for sale (See. 7044, Business ❑TENANT ❑FOODSERVICE IMPROVEMENT ❑ OTHER SWIMMING POOL ELECTRIC and Protes.sams Code: The Contractor's License Law does not apply to an owner III OUTLETS - SWITCHES -FIX'I'ORES property who bonds or improves thereon, and who does xuch work himself or through his own employees, provided that such Improvements are not intended or offered for NEW RESIDENTIAL HLECfR SQ FI: SQ. FE FLOOR AREA $/SQ. FT sale. If. however the building or improvement is sold within one yso dCo. pletion,the owner-huildu will have the harden n[pmving that he did not build nr improve fm purr- pose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to Js�+ TOTAL: aomand the prole d (See. 7044, Business and Pmfcietons GtdJ The Conductor§ LI- e Law does not apply it) an owner of property who builds or improves thereon, and QTY, PLUMBING PERMIT FEE � � g who contracts for such projects with a c.ntraenodid licensed pursuant to the Connector's (% PERMIT ISSUANCE License Low. ❑ I am exempt under See. ,B& P C for this reason ill / (ter L . Vg1111�� I D ALTER - DRAIN & VENT - WATER (EA) Owner Date BACK FLOW PROTECP. DEVICE WORKER'S COMPENSATION DECLARATION © fil- lfmt f the fallowing declaration I hereby aunder penalty of perjury one os: vl U DRAINS -FLOOR, ROOF,AREA,COND. ❑ I have and will maintain a Certilicaa of Consent t.self-ireure for Worker's Coupon- Emden, as provided for by Section TIDO Of the Labor Code. for the performance a the STORIES TYPE CONSTRUCTION FIXTURES - PER TRAP work for which this peCarl is issued. ❑ I have and will maintain Workers Compensation Insurance, as Te uired by Section 3701nf the Labor Code, for lheperhtrmance fthe work for which this permit is issued. GAS - HA. SYSTEM -1 INC. 4 OUTLETS OCC.GROUP APN My Worker's Compensation Insurance carrier and Policy number arc: Carrier: Policy No.: GAS- EA. SYSTEM -OVER 4 (EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thi,.,, n need nut Noompleted ifthe permit is for onehundreddollars SPOT to beat I GREASIJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES GREASETRAP PLI,NCHECK FEE Icerify that in theperfomanceofine work for which this permit is issued, l shall not employ any person in any manner s. re (n mm hee subject to the Workers' C.mpen- SEWER - SANITARY - S' FORM EA. 200 FT. ENERGY FEE WATER HEATER WNENTMLECfR cation Laws of Califs Dat Applicant t - GRADING FEE NOTI , u r makinK mix Cedificao of Exemption, you should became suhject to the Worker', Compensation powisions of the LoMd Code, you must WATER sysTEM/TREATING SOILS FEE forhwinconmply with suchprovision.sormispermit shall bedeemedrevoked. WATER SERVICE CONSTRUCTION LENDING AGENCY Iherehy affirm that mea ixamnswdion lendinK aKenty for the performance of PAID Dote Receipt# NEW RESIDENTIAL PLMR. SQ. FT. the work for which this permit is Issued (Ser. 3097, Civ. C) Lender's Name TOTAL: Lenders Address TOTAL: BUILDING FEE I verify that I have rend this application and sole that the above infmmmlon is amect.I agree to comply with all city and county ordinances and state laws relating e, building Conswction, and hereby authorize representatives of this city meaner upon the QTY. MECHANICAL. PERMIT PEE SEISMIC FEE Its -0 PERMIT ISSUANCE ELECTRIC FEE above-mentioned property for inspection pu,poses. (We) agree m save, indemnify and keep harmless the City of Cuperin t against ALTER OR ADD TO MECH. PLUMBING FEE liabilities,judgments, costs and expenses which may in any way income against said City' in consequence of the granting of this permit. AIR HANDLING UNIT (TO 1I,0TO CFM) MECHANICAL. FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGU TIONS AIR HANDLING UNIT (OVER 10,001 CFM) CONSTRUCTION TAX _ p¢ or Date HAZA US MATERIALS DISCLOSURE EXHAUST HOLD(W/WCD HOUSING MITIGATION FEE HEATING UNIT (TO 100,00) B'1 U) Will the applicant or future building occupant,uore or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety HEATING UNIT (OVER 100.00k) BTU) Code. Section 25532m)7 El Yes El No PAID - Date Recxipt # VENTILATION FAN (SINGLE RESID) BOILER - COMP OHP OR 100,000 BTU) Will the a licum or fold. huildin t use e t or devices which pp dby thea. Area emir hazardous air contaminants as defnW by the Bay Area Air Quality Management Qu Distrid9 ❑Yes F7 No TOTAL S BOILER - COST (OVER 101,IXq BTU) AIR CONDITIONER 1 have read the h ode, Se materials 5, 2553 an under 1 and rsta ofthe Cali h- that if the fomite Health &So&ty Code, Sections out.the"25533and 25534.1 to notify building does not currently have a anent, that it is my responsibility totthe oacup m the ISSUANCE DATE NEW RESIDENTIAL MECH. SQ. FT .foe reyuiamems which nmst be met primrtoissuanwnfa Cerifeao of Occupancy. ISSU[D BYVV L t9x^-tca• Owner or authoneed agent Date TOTAL OFFICE 0 • STATE P.O, BOX 807„ SAN FRANCISCO,CA 94101-0807 COMPENSATION •INSUPeAN CE FUND CERTIFICATE OF WORKERV CQMPENSATION INSURANCE POLICY'NFI"Ilk 1387801 - 87 ISSUE DATE: 08-01-97 .CERSIFICATE EXPIRES: 0e-01-98 CLAYTON BUILDERS'IINC ;708; PROOFiOF INSURANCE P 0 BOX 111$0) CERTIFICATE CAMPBELL CA 95011 This Is to certify that we have issued a valid Workers' Compensation insurance Dalley In a form approved by the ., California Cemmi{tSionar_to ;tpe,.omployezrtsmad lWow, for -Me poky'perlod I dkatad. _._... This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the l employer. We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of Insurance is not an insurance policy and does not amend, extend or alter the coverage. afforded by the policies listed heroin. NorwithsUnding any requirement term, or condition of any contract or other document with respect to which this certificate of insurance may be 1eaued or may pertain, the insurance afforded by the Policies described herein is subject to aN the terms, 'e7teluabns and conditions of ,yuch;poiiciss. 1. ,♦ ^ .... . `'.. 'PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDIIG OeriM f1, C6, ON. 00''PEA OCCURRENCE. EMPLOYER CLAYTON BUILDERS INC P 0 BOX 111807 CAMPBELL CA 88011 CLAYTON BUILDERS INC (A CORP) 07-18-87 InTwe�allralrenl 0