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25263LINES - CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT LICENSED CONTRACTOR'S DECLARATION Z I hereby affirm that len licensed under InewhiomofCbapter9(commencingwiM O Season, 7000) of Division 3 of th5,pusinas and Professions Code, and my license is in F or mrc` ansasean Do�tt/en��.�1/�_'y�S�_p6� C —0 3 8. 7. W License�Y�e—Cmm 2 ARholl be GTS DECLARATION I undermend my plana shall be used as public mounds. ,4 Ucensd Profeasmnal U OWNER -BUILDER DECLARATION 1 hereby uffima that 1 am exempt form the Con.mctorx License Law far the se following ..an.(Sadon7031.5, Business and Professions Cade: Anyciyorcounty which requires a permit to consumer, abet, improve, demolish, or repair my structure prior 1. its issuance, also requires the applicant for such Permit a file o signed staumem 00 that he is licensed pumuam to Me pmvisiom of the Conuanofs License Law (Chapter 9 (commensing with Section 7000) of Division 3 of the Business and Rofessiom Code) an or Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of QSeNan 7031 S by any ppPlicsat for a Permit subjects the applicant to a civil penalty of G not mom than rive hundred dollars (SSoo). ❑ I,mownerofrheproperry,armyemployees withwagesavtheirsolecompemauon, will do the work. and the structure is not intended or offered forate(Sm. 7044, Business and Pmfessions Code: The Cannoneer, License Law does not apply 1. on owner of property who builds or improves Merton, and who dos such work himxlfor through his own employees, provided that such improvements am not intended or offered for sale. If, however, Me building or improvement is sold within one year of compledon, the owner - builder will have the burden of proving Mar he did nor build or improve for purpose of sale.). ❑ Las awnerof Me property, stn Basin,. and Potracttions Cl10Th Cancraoto comwa the project gm.apply 7044. Bminess and y who CdeJ The Conon. an , License haw does not apply a an owner of property who se builds or improves thereon, end who commas for such projects with n wntrecmr(s) licensed pursuant to the Conuaztor s I.icenx Lew. ❑ 1 un exempt under Sm. , B & P C for this mason WORKMAN COMPENSATION DECLARATION t[hereby affirm thin i have a certificate ofcomem in self -insure or a certificate of keri Compensation Insurance or o certified copy Marea f(Ses. 3800. Lab C.) which coven all employer's under Mis permit. Certified copy is hereby fumiabd. as Certified copy is filed wird Ma city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the patient is forma hundeaddollon ($100) or leas.) I certify that in Me performance of Me work for which this permit is issued, I shell nor employ any person in may manner ao as to become subject to the Workers' Z Compensation laws of Celiforria. Dox Applicant 0 NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should rte. become subject to the Workers Compensation provisions of Me Labor Code, you must > forthwith comply with such provisions or this permit shell be deemed revoked. Iley A CONSTRUCTION LENDING AGENCY Z I hereby affirm that Jure is a construction lending agency for Me perfoommace of U O rhe work for which this permit is issued (Ser. 3097, Civ. C.) Lender's Name O V lenders Address 6: 1 certify Mat 1 have read this application and state Met Me above information is L1. correct. I agree to comply with all city and county ordinances sad state laws relating to V) building construction, and hereby suMorise represenxrives of Nis city an enter coca the U 2 above-mentioned pmpeny for inspection purposes. rte- We) agree to save, indemnify and kap harmless Me Citv of Cupertino aeeinst HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant some an handle haasrdous prou nal as defind by rhe Cupertino Municipal Code, Chapter 9.12. and the Health and Safety Cade, Section 25532(a)T ❑ Yea ❑ No Will the applicant or future building Occupant se equipment ordevices which emit hazardous air contaminants ex derined by the Bay Arca Air Quality Management District? ❑ Yes ❑ No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califamia Health & Safety Code, Secdons 25505, 25533 and 25534. 1 understand Mat if the building dues not currently have a tenant, that it is my responsibility to notify the cecupam of Me requirements which must be met prior to issuance of a Ceni0cate of Occupancy. Owner or authorized agent Date LOT# ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANRLS UP TO 200 AMPS SIGNS ELECTRICAL SPECIALCMCUIT/MISC. TEMP. METER OR POLE MST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEWRESMENDALELECTR _SQ.FT. TOTAL: PLUMBING PERMIT PERMIT ISSUANCE 1 ALTER - GRAIN & VENT- WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS- FLOOR. ROOF, AREA, COND, FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OUTLETS GAS - EA. SYSTEM -OVER 4 MA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASE TRAP SEWER - SANITARY - STORM EA, 200111'. WATER HEATER W/VENDELECTR SQ. FT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO I0,00) CFM) AIR HANDLING UNIT(OVER 10."CFM) EXHAUST HOOD (W/DUCD HEATING UNIT (TO 100." BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RISID) BOILER - COMP (3HP OR IOTOM BTU) BOILER - COMP (OVER I00." BTU) NEW RESIDENTIAL MECH. SQ. FT. TOTAL: 25263 SANITARY NO. APPLICATIONSUBMITTALDATE CONTROL # 95" 6 ❑ FEE BUILDING PERMIT INFO BLOC ELECT PLUMB MUCH ❑ ❑ 19 ❑ `^/ r�^y JOB DESCRIPTION e.F I� SQ, FT. FLOOR AREA S/SQ. IT. j �.E© ' JUTEi FEE FLOOD ZONE FEESUMMARY UTSIDC FEES SANITARY Y l RECEIPT'#_ SCHOOLTAX Y 1 r RHFIPT#_ PARK FEE Y _f RECF,IPT# BUILDING DIVISION 2 PLANCHECK EEE GRADING FEE SOILS FEE ENERGY HE PAID Dam Receipt # TOTAL: FEE BUILDING HE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTIONTAX PAID Dare A1® JIM 195 c1 BY: