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31272APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OFICUPERTINO BUILDING - ELBC`PR BUILDING DIVISION APPLICATION/PERMIT PLUMB NG - MECHAI CONTACT. ❑ Consult ni t Fees Paid by Applicant (Initial) 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing .lion 7000) of Dlvisio of the Bnew.smd Pmfcssi000ns CDode, my license is form smde / RA e Lic.M e' L Contractor_ CHITECTS DECLARAION 1 understand an, plana shall be used as public records OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Comrac,.ra License Law for the 3 d U following muton. (Section 7031.5, Business and Professions Code: Any city or county 0 �which requires it permit m verear ct, alter. improve, demolish, ar repair any snucture y prior m its issuance. 4180 requires the upplicam for such pcfmitm l ile a signed statement y that he is licensed pursuant o the provisions of the Contractor's License Law (Chapher9 00 (commencing what Section 7000) of Division 3 efthe Business and Pmfexonev Cnde)or p, =K that he is exempt therefrom and the basis for the alleged exemption. Any violation 0f i� 4th. Salon 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of F Z y not room Nan five hundred dollars (SSW). 'dox< D I. as owner of Ne pmpcny, or my employees with wages as their sole compensation, [..0 will do ate work, and Neewdure is not intended oroffercJ for sale (S.AIHd, Business 13 y and Pmfcssions Codd: The Combat 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 arc nm intended or offered for We. IL however, fie building m impmvernent is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for pur- 'pme of sale.). D L es owner of the property, am exclusively contracting with licensed contracton,. construct the project (S.. 7044, Business and Professions Cale:) The Conferences Li- mnsa Use does not apply,. an owner (if propcny who builds or i reproves lharcnn,and QTY, who contracts for such projects with a contractors) licensed Paramour to the Commemrs License law. ❑ I am exempt under Sec. ,R& P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty ofperjury one of the following declumtions: ❑ I have and will maintain a Certificate of Comentto self -insure for Workers Compcn- sodium, m provided for by Section 37W of the Labor Code, for the performance of the work for which Nis permit is issued ❑ 1 have and will maintain Worker's Compensation Imurmec, as required by Section 37Wof Nea ode. for Ne 'of.a"'e of the work form 'ch this Pe sissucd. My Worker' t e . ti TGs me anter and Policy nu be u Cartier: Policy No.: CERTIFICATECOMPENSATION INN FROM WORK RS' COMPENSATIONINSUR6NCE (This section need out be completed ifthe pemdt is for one hundred dollars IS I(q) tole ) 1 certify that in the perfonnmce of the work for which this permit is issued.) shall not employ any person in my manner so as m become subject to the Workeri m Copere �z sauon laws of Ciliforat Date z Applicant w+ Vl NOTICE TO APPLICANT: If, after making this Cer ifcme of Exemption, you should a5: become subject to Ne Worker's Compensation previsions of the Labor Otic, you must {2; Q forthwith comply with such provisions or this porom shall he domed revoked. z CONSTRUCTION LENDING AGENCY V l hereby affirm Not Nem is a construction lending agency for she performance of Tyr h Ne work for which this Permit is issued (Sec. 3097. Civ. C.) C U Lender's Name WIsndcrs Address Iy I sent that I have mad this application and slam that she above information is r fA emrect. I agree to comply with all city and county ordinances and stow laws relating to QTY, �.) Z buildingcousbaction, and hereby auUoriu representatives of Nis city,. ceterupon the above-mentmaed property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs ad expense which may in any way accrue egainxt said City in coesequ.we of the granting of this person. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SignaturemApplicaral untmctor - Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfurore th 'lding Occupant now r handle howe dmo nsworid as defined by the Cupenino Muni pal Cute, Chepmr 9."ch 2, and the Health and SafetyCode, Section 25532pd? - ❑Yea No e Will Ne .,lie or future hu' ing necupano use equipment or devices which emit hazmdmu air contaminants . efined by the Bay Awa Air Qudity Managcmcnt District? ❑ Yee I have wood the haoudous la wm quirecros under Chapter b 95 of the Cali - form. Health_& -safety CWc, 5'1 505, 25533 and 25534. 1 umlemwnd that if Ne ELECTRIC PERMIT I FEE PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UPTO 2W AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST POWER DEVICES I SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -Mc NEW RESIDENTIAL ELECTR PLUMBING PERMIT 1 FEE PERMIT ISSUANCE ALTER- DRAIN & 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( EA) GREASFANDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER -SANITARY -STORM EA. 2W IT. WATER HEATER W7VENT(ELECIR WATER SYSTEMWfRPAT[ NO WATER SERVICE NEW RESIDENTIAL PLMB, SQ. FT. MECHANICAL PERMIT I FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,(gg) CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT TIL, 1 W,000 BTU) HEATING UNIT (OVER 1 W,W0 Brut VENTILATION FAN (SINGLE RESID) BOILER -COMP (3HP OR 100.000 BTU) BOILER - COMP(OVEiR IWAW BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE IN MIAMI IIfieLo 72 JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ HEN REMODEL ❑ADDITION PLUMBING'RE-PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION L3 INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT ❑ BATH RE1,10DEUREPAIR ❑ DEMOLITION DOTHER COMMERCIAL ❑ NEW BLDG/ADDITION OTENANT IMPROVEMENT ❑ OTHER SQ. FT. FLOOR PA11) D DEMOLITION ❑ FOOD SERVICE Cqy VALVRWr)N l/ Ur UUrtn I RrU BUILDING DIVISION FRES PLANCHECK FEE ENERGY M% GRADING FEE SOILS FEE PAID Date Receipt ro TOTAL BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBINGof FEE MECHANICAL FEE I HOUSING MITIGATION FEE I PAID Date Receiplg TOTAL: