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30557APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO s - BUILDING 4 ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT: PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION _ PERMITNO. " 30557 BUILDING ADDRESS: ♦ w SANITARY NO. APPLICATION SUBMITTAL DATE G 6. OWNER' NA E: ONE: •WIN CO RACTOR'S NAM LIC NO: " 14 O N/C ❑ .., CO TROLp +. R I T/ENGINEER: LIC NO: - DDR S CONTACT: pxoNe: ' ❑ Consultant FeeS Paid: by Applicant (Initial) BUILDING PERMIT INFO I BLDG ELECT, PLUMB MECH '., ❑ ❑r. LICENSED CONTRACT'OR'S DECLARATION l hereby affirm Thal 1 am licensee under provisions od Chapter 9 (wmmense is Z with forceand at cDivisloo3 of the Buslneas and ProfeseVonv Coda, and my license is in full force and of c.,?y 3-S-410-'10, ,J,J License s J Lic.N J� 0 y Date ContreE QTY. ELECTRIC PERMIT FEE PERMIT ISSUANCE - JOB DESCRIPTION RESIDENTIAL . ❑SFDWL ❑KITCHEN REMODEL ❑ADDITION Ll PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION 0INTERIOR El CHIMNEY REPAIR IMPROVEMENT , ❑BATH REMODEL/REPAIR El DEMOLITION [D OTHER APPLIANCES - RESIDENTIAL n ARCHITECTS❑ECLA ION Z I understand my plans sh.11 be used as public records PANELS UPT02fH1AMPS Lsensed Pnskssnonal - ,' OWNER -BUILDER DECLARATION 1 hereby affirm'that 1 tan exempt from the Contractor's License Law for the following reason. (Section 9031,5, Business and Professions Code: Any city or county which requires a permit an coull ucl, eller, improve, demolish, or repair any swcmre prior to its issuance. also requires the applicant for such permit to file a signed statement that he is licensed pursuaat In the provisions of the Crmmrmr'a License Law (Chapter 9 (commencing with Section 7000) ofDivision 3 ofthe Business and Profexaion, Code)nr that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant In a civil penalty of not more than five hundred dollars ($S00). ? ❑I, as owneruf the property, or my employees with wages os theirsole compensation, will do the work, and the strugmre is vet intended orofiered lbr sale (Sce. 7044, Business and Professions Code: The Contractor's License Law dues not apply to an owner of property who builds or improves thereon, and who does such work himself or through his awn employees, provided that such improvements are not intended or offered for sale. If, however,'the building burden effort is sold within one yemofcomplmion,the owner -builder will have the burden of proving that he did not build or improve for pur- pose of sale.). D1, as owner of the property. um exclusively convecting with licensed contractors to construct the project(Sec. 7044. Business and Professions Care) The Contracmr'a Li- arise Law does not apply to an owner of property who builds or improves thereon, and who commets for such projects with a wntrvcmr(s) licensed pursuant to the Contractor's License Co. ❑ 1 em exempt under Sec. , B & P C for thio reason 301-1((ki OVER 1000 AMPS SIGNS ELECTRICAL' SPE AL CIRCUIT/MISC. EM P. METER OR POLE INST. COMMERCIALk ❑ NEW BLDG/ADDITION ❑ DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER DEVICES SWIM PO LELECTRIC r COMLETS - CHE - FIXTURES I ENTIA ELECTR SQ FT SQ.FTFLODRAREA^ ��� x7J V 1996 :. A'61 I 1 )�^ V�i 1,(1 i 1(110 $/SQ. FT ' t TOTAL: QTY. PLUMB PERMIT PEE PERMITISSUANCB ALTER. -DRAIN&VENT- WATER (EA) Owner_ Date VALUATION. - ' WORKER'S COMPENSATION DECLARATIO10 N Thereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain. CertifcateofCormin to self -insure for Worker's Compen- gotten, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.' ❑ I have and will maintain Worker's Compensation Insmame, as required by Section 37M of the Labor Cale, for the performance of the work for which this perm it is issued. My Work Crmpen ti tlnsomnce carter and Pirmy.qutyFl� Carver Policy No �'3.//i21, 3� CEE IT A OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be eomplmnd lithe permit Is forone hundred dollars (SI W) or lased permitirkeratropeall Loy any parsonany mannrof become not employ any person in any manner so as to become subject m the Workers.' Compen- subject gaunt Laws of Califnmin. Date NOTICE TO APPLICANT: If, after maing Nis Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Laher Cale, you must forthwith comply with such provisions or this permit thrill med ll be deerevoked. .' CONSTRUCTION LENDING AGENCY Thereby affirm ohm there is. gouswctinn lwdiug vgency frrtheperformanceof the work for which his permit is issued (See. 3097, Civ. C.) Lender's Name' Lenders Address T certify that 1 have read this application and state that the above information is correct l agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the abovetmentioned property for inspection purposes. Cupertino against .(We) agree to save, indemnify end keep hay in an the City accrue may in any way accrue against said Cityin liabilities,judgmentse granting expenses thisPermit, consequence Nthegranting SthisDWiL APPLSOURCE RE UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. } BACK FLOW PROTECT. DEVICE DRAINS- FLOOR, ROOF, AREA, COND. ' STORIES - - TYPE CONSTRUCTION FIXTURES -PER TRAP GAS- EA. SYSTEM. I INC. 40TTI PTR OCC. GROUP qPN ' GAS - EA. SYSTEM -OVER 4(EA) DUSTRL WASTE INTER "OR RAP BUILDING DIVISION FEB PLANCHECK FEE ANITARY-STORM EA. 200 FT. EWATER ENERGYFEE ATER WNENT/ELECTRApplic.ntGRADING STEMRREATING FEE SOILS SOILS FEE WATER PAID Dara Rcvc,ak NEW RESIDENT JAL PLMB. SQ. Pf. ., TOTAL: BUILDING FEE QTY. MECHANICAL PERMIT FEE SEISMIC FEE PERMIT ISSUANCE ELECTRIC FEE ' ALTER ORADDTO hl PLUMBING FEE AIR HANDLING UNIT(TO IR0MCFM) MECHANICALFEE , AIR HANDLING UNIT (OVER to," CFM) CONSTRUCTION TAX . Signature of Applicart Comracmr Dine. HAZARDOUS MATERIALS DISCLOSURE Will theappliemit or future building occupant Itiorm handle funeral ..[coal as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety -Code, Section 25532(.)9 'eyes ❑Na - Will the applicant or future building occupant use equipment or devices which emit hazareous air contaminants as defined by the Bay Arca Air Quality Management District? ,Dyes " DNo T have read the hazardous materials requirements under Chapter 6.95 of the Cali- madia Health & Sidney Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant that in is my responsibility m notify the occupant of the requirements which must be met prior m issuance of a Certificate of Occupancy. EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT (TO 100,00) BTU) HEATING UNIT (OVER 100,000 BTU) t PAID Dane Receipts VENTILATION FAN (SINGLE RP,SID) BOILER- COMP QHP OR 100,000 BTU) - TO , BOILER-COMP(OVER100,000BTIp AIR CONDITIONER ISSUANCE DATE ' ISSUED BY: NEW RESIDENTIAL MECH. SQ. FT. Ownerorauthanmdagent - Date H TOTAL: • OFFICE APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO s - BUILDING 4 ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT: PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION _ PERMITNO. " 30557 BUILDING ADDRESS: ♦ w SANITARY NO. APPLICATION SUBMITTAL DATE G 6. OWNER' NA E: ONE: •WIN CO RACTOR'S NAM LIC NO: " 14 O N/C ❑ .., CO TROLp +. R I T/ENGINEER: LIC NO: - DDR S CONTACT: pxoNe: ' ❑ Consultant FeeS Paid: by Applicant (Initial) BUILDING PERMIT INFO I BLDG ELECT, PLUMB MECH '., ❑ ❑r. LICENSED CONTRACT'OR'S DECLARATION l hereby affirm Thal 1 am licensee under provisions od Chapter 9 (wmmense is Z with forceand at cDivisloo3 of the Buslneas and ProfeseVonv Coda, and my license is in full force and of c.,?y 3-S-410-'10, ,J,J License s J Lic.N J� 0 y Date ContreE QTY. ELECTRIC PERMIT FEE PERMIT ISSUANCE - JOB DESCRIPTION RESIDENTIAL . ❑SFDWL ❑KITCHEN REMODEL ❑ADDITION Ll PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION 0INTERIOR El CHIMNEY REPAIR IMPROVEMENT , ❑BATH REMODEL/REPAIR El DEMOLITION [D OTHER APPLIANCES - RESIDENTIAL n ARCHITECTS❑ECLA ION Z I understand my plans sh.11 be used as public records PANELS UPT02fH1AMPS Lsensed Pnskssnonal - ,' OWNER -BUILDER DECLARATION 1 hereby affirm'that 1 tan exempt from the Contractor's License Law for the following reason. (Section 9031,5, Business and Professions Code: Any city or county which requires a permit an coull ucl, eller, improve, demolish, or repair any swcmre prior to its issuance. also requires the applicant for such permit to file a signed statement that he is licensed pursuaat In the provisions of the Crmmrmr'a License Law (Chapter 9 (commencing with Section 7000) ofDivision 3 ofthe Business and Profexaion, Code)nr that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant In a civil penalty of not more than five hundred dollars ($S00). ? ❑I, as owneruf the property, or my employees with wages os theirsole compensation, will do the work, and the strugmre is vet intended orofiered lbr sale (Sce. 7044, Business and Professions Code: The Contractor's License Law dues not apply to an owner of property who builds or improves thereon, and who does such work himself or through his awn employees, provided that such improvements are not intended or offered for sale. If, however,'the building burden effort is sold within one yemofcomplmion,the owner -builder will have the burden of proving that he did not build or improve for pur- pose of sale.). D1, as owner of the property. um exclusively convecting with licensed contractors to construct the project(Sec. 7044. Business and Professions Care) The Contracmr'a Li- arise Law does not apply to an owner of property who builds or improves thereon, and who commets for such projects with a wntrvcmr(s) licensed pursuant to the Contractor's License Co. ❑ 1 em exempt under Sec. , B & P C for thio reason 301-1((ki OVER 1000 AMPS SIGNS ELECTRICAL' SPE AL CIRCUIT/MISC. EM P. METER OR POLE INST. COMMERCIALk ❑ NEW BLDG/ADDITION ❑ DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER DEVICES SWIM PO LELECTRIC r COMLETS - CHE - FIXTURES I ENTIA ELECTR SQ FT SQ.FTFLODRAREA^ ��� x7J V 1996 :. A'61 I 1 )�^ V�i 1,(1 i 1(110 $/SQ. FT ' t TOTAL: QTY. PLUMB PERMIT PEE PERMITISSUANCB ALTER. -DRAIN&VENT- WATER (EA) Owner_ Date VALUATION. - ' WORKER'S COMPENSATION DECLARATIO10 N Thereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain. CertifcateofCormin to self -insure for Worker's Compen- gotten, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.' ❑ I have and will maintain Worker's Compensation Insmame, as required by Section 37M of the Labor Cale, for the performance of the work for which this perm it is issued. My Work Crmpen ti tlnsomnce carter and Pirmy.qutyFl� Carver Policy No �'3.//i21, 3� CEE IT A OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be eomplmnd lithe permit Is forone hundred dollars (SI W) or lased permitirkeratropeall Loy any parsonany mannrof become not employ any person in any manner so as to become subject m the Workers.' Compen- subject gaunt Laws of Califnmin. Date NOTICE TO APPLICANT: If, after maing Nis Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Laher Cale, you must forthwith comply with such provisions or this permit thrill med ll be deerevoked. .' CONSTRUCTION LENDING AGENCY Thereby affirm ohm there is. gouswctinn lwdiug vgency frrtheperformanceof the work for which his permit is issued (See. 3097, Civ. C.) Lender's Name' Lenders Address T certify that 1 have read this application and state that the above information is correct l agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the abovetmentioned property for inspection purposes. Cupertino against .(We) agree to save, indemnify end keep hay in an the City accrue may in any way accrue against said Cityin liabilities,judgmentse granting expenses thisPermit, consequence Nthegranting SthisDWiL APPLSOURCE RE UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. } BACK FLOW PROTECT. DEVICE DRAINS- FLOOR, ROOF, AREA, COND. ' STORIES - - TYPE CONSTRUCTION FIXTURES -PER TRAP GAS- EA. SYSTEM. I INC. 40TTI PTR OCC. GROUP qPN ' GAS - EA. SYSTEM -OVER 4(EA) DUSTRL WASTE INTER "OR RAP BUILDING DIVISION FEB PLANCHECK FEE ANITARY-STORM EA. 200 FT. EWATER ENERGYFEE ATER WNENT/ELECTRApplic.ntGRADING STEMRREATING FEE SOILS SOILS FEE WATER PAID Dara Rcvc,ak NEW RESIDENT JAL PLMB. SQ. Pf. ., TOTAL: BUILDING FEE QTY. MECHANICAL PERMIT FEE SEISMIC FEE PERMIT ISSUANCE ELECTRIC FEE ' ALTER ORADDTO hl PLUMBING FEE AIR HANDLING UNIT(TO IR0MCFM) MECHANICALFEE , AIR HANDLING UNIT (OVER to," CFM) CONSTRUCTION TAX . Signature of Applicart Comracmr Dine. HAZARDOUS MATERIALS DISCLOSURE Will theappliemit or future building occupant Itiorm handle funeral ..[coal as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety -Code, Section 25532(.)9 'eyes ❑Na - Will the applicant or future building occupant use equipment or devices which emit hazareous air contaminants as defined by the Bay Arca Air Quality Management District? ,Dyes " DNo T have read the hazardous materials requirements under Chapter 6.95 of the Cali- madia Health & Sidney Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant that in is my responsibility m notify the occupant of the requirements which must be met prior m issuance of a Certificate of Occupancy. EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT (TO 100,00) BTU) HEATING UNIT (OVER 100,000 BTU) t PAID Dane Receipts VENTILATION FAN (SINGLE RP,SID) BOILER- COMP QHP OR 100,000 BTU) - TO , BOILER-COMP(OVER100,000BTIp AIR CONDITIONER ISSUANCE DATE ' ISSUED BY: NEW RESIDENTIAL MECH. SQ. FT. Ownerorauthanmdagent - Date H TOTAL: • OFFICE