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25791E CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT 10493 4. DLAWZA >3WD. '7TOWO-R10= 241.14110 LICENSED CONTRACTOR'S DECLARATION Q=z IhembynffsrmlhallsmlicensedunduprovisionsofChapia9(conunencingwith 1+100Section]000)of Division 3ofthe fbadmetend Profession Code, andmy liermeis in EW W,Erc fullfoeaddra.1. <ZW Licenx Lie.# tt, Data Contacts y ARCHIT CTS DECLARATION NG 01 z� w 1 u Tan Y Plans d u m ubl' rds. ^� ....-...41tI Licen dPmboaimml (I OWNER -BUILDER DECLARATION nxpXOr1F 1 hereby aRmt that 1 am exempt from the Cmumpar's License Low f,eg� Ixl34y followldgreuxn.(Sect ion ]OILS, Business and Professions Code: Any city or colµ, ^ O ¢ which requires a permit to contras, alter, improve, demolish, or repair any strucnue prior to its issuance,aiw requires the applicvd for such permino file eslgnectmament <0 that he is licensed pursuant to the Provisions of the Cmuro mr's License Law (Chapter a�o 9(mmmeacing with Section 7000) of Division 3 of Business and Professions Code) W _tin or that he is exempt therefrom and the basis for the alleged exemption. Any violation of I=Ka Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of CFF not more than five hundred ddlam ($500). Co ❑ I,mowderofthepropeny,ormycmployeeswithwagesostheirsolecompensadon, y3. wil l do the work, and the structure is not intended or offered for aale(Sec.]044, Business and Professions Cole: The Commepr s License Law does not apply to m owner of property who builds or improves thereon, and who does such work himsel f or through his own employees, provided thmsuch improvements vent intended or offered for sale. If, however, the building or improvement is sold within tine yearofcompletion, themmer- buildcr will have the burden of pmving that he did not build or improve for purpose of toda ❑)I, as owner ofshe property, am exclusively contracting with licensed contractors to / construct the project (Sec. 7844. Business and Professions Code:) The Covumrs / License Law does not apply men owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s) licensed prommat to an, Conmecmis Lie.an Law. ❑ 1 am exempt under Sec. . B & P C far his renown WORKMAN COMPENSATION DECLARATION ❑ Ihveby effum thvlhave ocenificam ofconxm mxlGireurc,on cerifcate of Workers' Compensation Imuran or a certified copy thereof (Sec.38 W, Lab C.) which covers all employee's under this permit ft 14'1100 Policy# I{.� �7 7 Company IDF ❑ Comfied copy is hemby furnished, � C- w A. ❑ CcnifiW copy is fila) with the city inspection division. CERTIFICATE OF EXEMPTION PROM WORKERS COMPENSATION INSURANCE ("is section rad not be completed if the permit is for one hundred dollvs ($100) or las.) I certify that in the perfonance of she work for which this permit is issued, l shall not employ my Person in soy manner so as to became subject to the Wmkars' Comptuminn Lewsof Califant Data Applicant NOTICE TO APPLICANT: IL after makingthis Certificate of Evert ion, you should becomeh emptothe such pr Compensation provisionof celabor Code,you must forthwith comply with such provision or this Permit shill be decmed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that thou is a construction lending agenry for she performance of the wok fm which this pemdt is issued (Sec. 3097, Civ. C.) Lender's Namc Leader's Address I mrify then 1 have rend this application and spur that the above Informmon is comet, I agree to comply with all city and county ordinances and state laws talent,to It to ngcon,eion, ndh by archaize rcprasenpdvesofthiscitymemeruponshe above-memian p perry o mm, dotta��fpurposy (Wc)..- too*,nemn an kap tltly aye Cityof Cupertinoid City liabilities, dgme ts, de hie ay anywayacef C.' i said m;' 'I iIAZA US MATERIALS DISCLOSURE e Will the applicant m future building occupant store or handle hamardous anaredd as defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Sofeny Cole. Section 25532(x)? ❑ Yes )(No 0 Will sheapplicans orfuture building occupanmx equipment or devices which emit hazardous air wntaminaau as defined by to Bay Area Air Quality Management District) ❑ Y. )(No I have read the hazmdous materiels xquimmems under, Chapter 5.95 of the Celifumia Iieelth &Safety Cale, Scniam 25505, 2553] end 25534. 1 th dersumd that ifthe budding does not currently have a tenant. that it is my responsibility to notify the occupant of the nen which met prior m issuance of Cenif ate of ccupancy. /I eq�'e . i _ _ ..l .. Ic„ as POINT PEN ONLY -1111LT5tM17rRLECTRInr- PLUMBING: MECHANICAL ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANELS UP TO 200AMPS -_1 25791 SANI'T'ARY NO. APPLICATION SUBMITTAL DATE N2 CONTROL# CA ❑ FFP BUILDING PERMIT INFO LDG BpEFrI' JUN NNattP U AE RIPI'ION FLOOR AREAWQ. Ff. ���/I� TLE ©T � I O Y V a 0, � 1• II V IGIITLEf$-SCFIES -FIXTURES NEW RESIDENTIAL ELECfR _SQ.F PLUMBING PERMIT PERMIT ISSUANCE ALTER - DRAIN & VENT - WATER BEG 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. 20EFT. WATER HEATER W/VENTMLECfR WATER SYSTEMTREATING NEW RESIDENTIAL PLMB. SQ, IIT, MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (I'0 10,000 CFM) AIR HANDLING UNIT (OVER I0,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) I MATING UNIT (OVER IM." BI U) VENTILATION FAN (SINGLE RESID) BOILER - COMP (311P OR 100,000 BTU) BOILER - COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH.-SQ. FL FEE FEF. FEE SUMMARY PARK FEE Y N_ RECEIPT# BUILDING DIVISION PEES PLANCHECK PEE GRADING FEE SOILS FEE ENERGY FEE PAID Date Receipt# TOTAL: BUILDING PER SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX PAID Date Receipt# TOTAL. ISSUANCE. DATE PAI NOV 23 190 It CI I Y Vr wrtri I BVU ISSUED BY: