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S 2681APPLICANT TO FILL IN INFORMATION WITHIN RED LINT CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT BUILDING ADDRESS. OWNER'S 01110"PSa411EI Inc ULJ..I rnot1�1 ni 1 - LICENSED CONTRACT'OR'S DECLARATION 1 hereby affirm that 1 am licensed under previsions of Chapter 9 with Seetion 711(I(B of Division 3 of the Bi sines and Professions Code, ed in full endeff i a! o.� License roe an Lf, a 1 understand my plans shall he uou'I m public records - USE BALL POINT PEN ONLY BUILDING - ELECTRICAL PLUMBING - MECHANICAL. BUILDING PROIF.LT IDEN'ri FICA'1'IfEN :ONTRACTOR'S NAME: LIC NO', Ro'/cL1 f'©otS 5'!),, 7J a! aDDlepss: aaV C-0-,, en Ave- ❑ Consultant Fees Paid by Applicant (Initial) QTY ELECTRIC PERMIT FEF. PERMIT ISSUANCE 1 APPLIANCES - RESIDENTIAL PANELS UPTO 200 AMPS 4 Fly Licensed Poinwimtal Yf; OWNER.BUILDHR DECLARA'PION s � 6 1 hereby affirm that 1 am exempt from the Contracmr'x License Law for the 0.V following reason. (Section 7031.5. Business and Prefeetom Cade: Any city or county W O F which amainmit , a perla coni ate" improve, demolish, re repair any someone poor to its issuance, also resturea the applicant for such permit to Me a signed.,no men, toThar he is licensed pnsinal othe provisions ofthe Contractors License Low (Chapter 9 CCa0 (romdwead.g with Section 700) Division Sof the Hanine,wal Professions Glide)., q o o�C that he is exempt therefrom and the basis for the alleged exemption. Any violation of W y Section 7031.5 by any applicant for a Permit.subjecta the applicant to a civil penalty of mora Than five hundred dol Iwo ($5110). C G ❑ 1, as owner of the property, or my employees with wages as their sale compensation, 2� will do the work, and the structure is not intended or offered for sale (Sm. 7044, Business {Wial m and Professions Code 'Me Contractor's License Law does not apply to an owner of pmpeny who builds or improves thereon, and who does such work himself or through his own employees, pmvidcd that such improvements are not madndtd or offeed for sale. IL howeveq the building or improvement is sold within one year of cnmpledoo, the wnenbudder will have the burden of proving that he did not build or improve for pur- poseofsulc.), ❑ [,;is owner of the property am exclusively contracting with licensed comravmrs to commuet the project (Sec. 70,1,,1, Business and Professions Code.) The Contractors Li. cond, Law does not apply to an owner f properly who builds or improves thereon,and QTY. who caramels for such projects with a vorlov or(a) licensed pumanntto the Contravenes Licem , Law. I am exempt under Sec. , H & 1' C for this reason SIGNS ELECTRICAL SPECIAL CIRCUITIMISC. TEMP. METER OR POLE INS F. POWER DEVICES SWIMMING POOL ELECTRIC OU'1'LE TS - S W ITCI WS - FIKTIJRES NEW RESIDEM'IAL ELE(7R Owner Dale WORKER'S COMPENSATION DECLARATION I hereby affirm undo, penally of perjury one of the fallowing declarations: 1 have and will mai main a Certificate of Consent to self -insure for Workers Cultism. One, a, provided for by Scotian 37M of the Lahr Cale, for the performance of the work for which this permit is issued. ED I haveand will maintain Worker's Compensation Insurance, sea required by Section 730700 of nor Code.forthe perfirzmance of the work lin whiclo his permit isnsadd. My Walker' Coal nxmias lnsumnco curie, and Polies u th Clrrie. Pultoy,o.: CE 'ATED EKEMPIIONFAOMWOR ERS' COMPENSATION INSURANCE (This section need not bressa ,ted ifthepermil is Europe hundred dollars (8 Put or less.) I certify del in the performance of the send for which this pertnil is issued, l shall not employ any person in any manner so as to beano subject to the WorkersCompen- s aito Lows of Cullfornia. Dale ZO Applicant ` N. NODCF. TO API'LICAN'T: IL afar making this Cerlificnlc m Exenhption. you shomto 5become subject to the Workers Compensation provisions of the Labor Cade, you moor fnnhwilh comply with such provisions or this permit shall No dcemed revoked. Q CONSTRUCTION LENDING AGENCY U Q l hereby affirm Beat is a construction lending agency for its, performance of W F the work for which alis permit Is issued (Sec. 3097, Civ. C.) OV1<ndees Name ULender's Address W I minify that 1 have read this applicstian and some that he abhwe information is nF-t fR1 correct I agree to comply with all city and county ordinances and nate laws relating to QTY U Z building construction, and herehy uuthnrire representatives of this city to enter upon the abtwe-mentioned property for Inspoction purposes. (We) agree m suet, indanmify and keep hornless the City of Cupertino against thevilinea,judionerts, rival and expenses which may in any way accrue again,, said City in n,,mmm of the granting of this pewit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE Rf:QULATIO Signature of ApplicargCon,ractor 1 am HAZARDOUS MATERIALS DISCLOSURE Will the applicant it future building occaponl sere or handle hazardous material in defined by the Cupertino Municipal Cele, Chapter 9.12, and the Heath and Stdcry Code. Section 25532(a)! ,, ❑Yes De Will ,he applicant or (alone (wilding amupanl use rempmen, or deviems which mil harardnus air contaminants as delnad by the Bay Area Air Quality Management District? ❑Yes P I I hav rust the loo,orJous materials e9uis meat, under Chapter 11.95 of the Cali - term Ile & Safe,y Code. Sections 8505, 25533 and 25534. 1 andctzhand Bat if the bvih% dons nurrmanetlfylwea_ arms, audit isneyeesprribilitym assfy the occupant PLUMBING PERMIT PERMIT ISSUANCE AI:1'F.R-DRAIN&VIiN3'- EIt (IiA NACK FLOW PROTECT. EVE DRAINS -FLOOR, ROOF.AREA, CONI I'T"IRES - PER TRAP GAS- FA. SYSTEM -1 INC. 4 OUTLETS GAS - P.A. SYSTEMTOVER 4 EPA) GREASE ?'RAI` SEWER -SANITARY WATER HEA'T'ER WA WATER SYSTEM?RI WAITS SERVICE lri� ❑ l yZo BUILDING Efl, ❑ ❑ ❑ JOB DESCRIPTION RESIDENTIAL ❑SFUWI. ❑ KITCHEN REMODEL ❑ADDITION Ll PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL. MODIFICATION ❑ INTERIOR CHIMNEY REPAIR IMPROVEMENT WIMMING POOLS ❑ BATH RP.MODIiVREPAIR DEMOLITION ❑ OTHER COMMERCIAL ❑ NEW BLDUADDITION ❑DEMOLITION ❑TENANT' ❑ FWD SERVICE IMPROVEMENT ❑OT ER SQ IT. FLOOR AREA LSQ.T OTA /J FEE VALUATION r„ A n 0 20o FT. MECHANICAL PERMIT PERMIT ISSUANCE AUFER OR ADD TO MECH. AIR HANDLING UNIT (TO IOJI(a) CFM) AIR HANDLING UNIT (OVER 10,010 CFM) EXHAUST HOOD (WIDUC9') H17ATING UNIT (TO 100,0011 BTU) HPATING UNIT OVER 1011.0111 BTU) VENTILATION FAN (SINGLE RESIDE BOILER -COMP tJHP OR 100,0011 BTU) BOILER -COMP (OVER 10 0,(NIO BTU) AIR CONDITIONER NEW RESIDENTIAL MUCII. SQ. rT. Oce. unser ZrreOS 7 0 � ca,✓ BUI G DIVESION FEIiS _ PLANCHECK F' `;CNI Q - Z 0 PAID BUILDING PEI? FEE SIiiSMIC F1111, CONSUC "ON TAX 1{OUSIN MITIGATION FEE PAID Date Receipa TOTAL) I ISSUED IIY: OFFICE ISSUANCE DATE II(/ /- S' Q