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30408APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO ❑ ❑ ❑ SPECIAL CIRCUITMISU BUILDING - ELECTR BUILDING DIVISION APPLICATIONIPERMIT POWER DEVICES PLUMBING.MECHAI SWIMMING POOL ELECTRIC 1 BUILDING PROJECT IDEM BUILDING ADDRESS: MOTT c3 2S%- /I7I . 'W.1 rr I 5&&),rm, CONTACT: .❑ Consultant Fees Paid by Applicant (Initial) 1 hereby affrm into I am licensed tinder provisions of Chapter 9 (commencing QOwith Section 7")of Divisiom3 of the Business and Dofessimus Code. and my license is in full force and effect. <F.UZ� License Class Lic.g N Q Date Contractor b-�yy ARCHITECTS DECLARATION CZ J K 1 nndcrstand my plans shall he used as public mcoms � 4 [J.; Licensed Professional a4 •,,,)•1 OWNHR-BUILDER DECLARATION C G 1 hereby affirm that 1 am exempt from the Commerce s License law for the aC. FU. following mason. (Section 7031.5, Business and Professions Code: Any city or county P. yj which resume, a Permit to construct, alter, improve, demolish, or repair any structure gpoor to its issuance. also retainer Ne applicant for such Permit o 111c a signed statement rWvW�s} that he is licensed pars amvo the provtvia of the Committees License Law (Chaim,9 50� (commencing with Section 700H of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of ro N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of y i of marc than Eve hundred dollars (x500). SQ 1__1I,asowne101l proparty,.rmyemployeeswithwagesastheirsolecumpensmi.., calwill do the work, and the urunure is not intended or offered for sale (Sec. 7094. Business W and Profession Code: The Centimeter's License Law does not apply to an owner of property who builds or improves thereon. and who does such work himself or through his own employees, provided that such improvements am net intended or offered for sale. If, however, the building or improvement is sold within one yea o(comptcoon, the owner-buildcr will have the burden of proving that he did not build or Improve for pur- p.so of ole.). ❑ 1, as owner of the propcny, am exclusively contracting with licensed cantmemrs to contact the project (Sec. 7044, Business and Professi.m Cam) The Contractors Li- enee Low does not apply to an owner of property who builds or improves thereon, and QTY, who contracts for such pmjmts with a co mwou(s) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. , B & P C for this ma5.n Owner Date WORKERS COMPENSATION DECLARATION r hereby o0rm sealer penalty of perjury one of the following decimations f- beend will mainmin a Cenifcate of Consent m self -insure for Winces Camper. saran, as po„ nvidcd far by Section 37M of the Labor Code, for the pertmtrmnce of the won for which Nis permit is issued. ❑ 1 have and will maintain Worker's C.mpensvtinn insuame, as required by Section ARID of the Labor Code, for the perfamance of the work for which this permit is isnued, My Work ooNmm card" and Policy n 4li Carver `Be as %+un Policy No.:+ ` 7-9 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the Permit is for one hundmildollas ($100) or less.) I rectify that in the performance oOhe work for which this permit is issued, I shall not employ any person in any manner se as to become subject to the Workers' Compcn. z sit.. laws of California. Dam O O APPlicam y NOTICE TO APPLICANT If, after making this Certificate of Exemption, you should a� become suhjee m the Worker's Comperamion.... isions m doe Labor Code, you most {:I forthwith comply with such provisions to this permit shall be deeroked m krd. z CONSTRUCT ION LENDING AGENCY L) O l hemby affim that hem iso cmna momm Imi ing agency for the performance of (L F' the wok for which this permit is issued (See. 3197, Civ. C.) O Imalere Name W Iendees Address 4y 1 certify that I have read this application a it some that the above information is tRJ coronet I agree m Comply with all city and county omiromces and state laws relining m QTg U z building construction, and hereby authorize representatives of this city to emeuts, the above-memiuned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City .f Cupeninn against liabilities, judgments, cap end expenses which may in any way accrue against said City onsequcnce the p�Tmingof 1101 ", APPLICANT DF STANDS A ' WILL COMPLY WITH ALL NON -POINT Will the applicant or future building Alcapant stem or handle humorous material a defined by the Cupertino Municipal Cede. Chapter 912, and the Health and Safety Code, Section 25532(x)^ C] Yet ❑No Will the applicant or future building occupant use equipment.. devices which kmodom air contaminants as defined by the Bay Area Air Quality Management ? ❑Yet No I have read the harardous materials requirements under Chapter 6.95 of the Cali - Extra Health & Safety CWc, Sections 25505. 25533 and 25534. I and erehard that if doe building does not cunendy have a tenant that n is my responsibility t. notify the occupant .f the m,linaments which must be met prior to issuance of a Cmifieae of Oveup it, ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UPT02MAMPS SIGNS ELECTRICAL ❑ ❑ ❑ SPECIAL CIRCUITMISU FEE TEMP. METER OR POLE INST. t POWER DEVICES t SWIMMING POOL ELECTRIC 1 OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR SQ Ef. PLUMBING PERMIT PERMIT ISSUANCE )' ALTER- GRAIN & VENT- WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS- FLOOR. ROOF, AREA, CORD. FIXTURES - PER TRAP GAS - EA. SYSTEM-] INC. 4 OUTLETS GAS - EA. SYSTEM -OVER 4 (PLA) GREASFJINDUSTRL WASTE INTERCEPTOR' GREASETRAP SEWER -SANITARY -STORM EA. 200 FT. WATER HEATER WNEWIELECTR WATER SYSTENUTREATING WATER SERVICE NEW RESIDENTIALPL IB. SQ. FT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MF -CH. AIR HANDLING UNIT(TO 10,000 CFM) AIR HANDLING UNIT (OVER 10.00) CFM) EXHAUST HOOD (WB3UCT) HEATING UNIT (TO IM." BTU) HEATING UNIT (OVER IM." BTU) VENTILATION FAN (SINGLE RESID) BOILER - COMP (AHP OR 100.000 BTU) BOILER -COMP (OVER 100,000 BTU) AIR CONDITIONER ' NEW RESIDENTIAL MECH. SQ. ET. OFFICE AUG 191996 11 FP,E +�)' VI"kaUI-L-LIbvV ❑ ❑ ❑ FEE JOB DESC PTION RESIDENTIAL ❑SFDWL \❑,��CHEN REMODEL ❑ADDITION j LUNCHING RE -PIPE' ❑MULTI -UNIT ,❑S RUCTURAL MODIFICATION C:1 INTERIOR El CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEUREPAIR C1 DEMOLITION ❑ OTHER BUILDING DIVISION R PLANCHECK FEE ENERGY FEE GRADING FEE COMMERCIAL' ❑NEWBI.DGIADDITION ❑DEMOLITION SANT ❑FOODSERVICE IMPROVEMENT ❑ ER PAID Data Receipt p TOTAL', AUG 191996 11 FP,E +�)' VI"kaUI-L-LIbvV OCC. GROUP BUILDING DIVISION R PLANCHECK FEE ENERGY FEE GRADING FEE SUITS FEE PAID Data Receipt p TOTAL', BUILDING FEE FEE SEISMICFEE ELECTRIC FEE PLUMBING FEE MECHANICAL. FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Dam Rereiptg