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B 0106APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING -ELECTRICAL. BUILDING DIVISION APPLICATION/PERNIIT TILECBANICAI. BUILDINNGG R 1'R0JIrCJI?C'T IDN:NTIFICA COMPACT: ❑ Consultant Fees Paid by Applicant (Initial) 1 herebyaffirm that I am licensed under fCha ter 9 (commends QTY. ELECTRIC PERMIT EEE a Provisinsa p g Pit ce Z with Section 7000) of Division 3 ofthe Business and Professions Code, and my license is H,Zi i a fad l firm and effect. QU U License Class Lic. a HQ w Date Cramosemr ARCHITECI'S DI?CLARSHON Z ~O cn Z [ understand my plans shall he used as public records Bz�❑ N titiee .F. LL1 Licensed Professional y j OWNER -BUILDER DECLARATION C Q I hereby aBinn that 1 ver exempt form IM1e Cnmmenrt's License Low for the X 3 Q. U following reason, (Section 7031.5. Business and Professions Code: Any city or county W 0 N which requite.. a Permit to construct, alter, impose, demolish, or repair any awcture F y Penn to itsi"trance. nbnrcquin, the upphrica f.,,.eh permit ftlensignWswmmmu mat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 X00 (commencing with Section 7000) of Division 3 of be Business and Profusions Code)or d L e ce that he is exenmt dead- a roil the EW, fee ,he allugal cxcnmtion. Any violation of WM y Section 7031.5 by any applicant for a Permit mucds the applicant to a civil Penalty of not more than five hundred dollars (SNxin. I] I, us owner aflhe Pr,pery, or my caleoyca, with wages ax lheirard mn,penwtinn, 2 p. willdm thework,and thestruaureis not intended oroffctM for sale(Sm.J044. Business a 3 and Profexxion.s Code: The Contractor's License Law does not apply to an owner of Cisproismy who builds or improves thereon, and who docs such work I lmself or mmugh his own employee., provided that such improvements are not intended or offered for sale. If, hrwevee the building or impmvement is sold within one year of completion.,hc ownar.hu will have the burden of proving that he did not build or improve for put - ,so of sale.). I] I, as swner of the propmny, am exclusively contracting with licensed craboomrs n, construct the project (Sec. p, Business and Professions Code:) The Contractors Li- ce l W ine Law does not appy to an�A4KT improves bureau, and QTY. who contracts for. such projcgs e to the Cnmmnam's License Law. _ Cl 1 am exempt under Sec/B & P Cfor this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following dwlarati n,x. 1 have and will maintain v Certificate of Consent to self dome for Workers Compen- sation, as provided for by Section 3700 of the labor Code, for the pedooman<c of the work I which this permit I, issued. C] 1 have and will maintain Worker, Compensation has ... ce as required by Section 3700 alike Labor Cale, for the permrtnance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section ncaJ mm be completedif the pemut is foronc hundmddollms(SI00) or le") I aertil'y but in the performance of me work for which this permit is i ... ed. l shell not employ any Person in any mannerso as to become subjec, to be Workers' Compen- O z sedan Laws of California. Dote Z Applicant ) N NOTICE TO APPLICANT: IL after making bis Coincide of Exemption, you should !Yi lwwme object to the Workers Compensation provisions of the Labor Code, you most forthwith comply with such pow,io., or this permit shall be deemed revoked. 0 =z CONSTRUChem iso ITONLENDING ngAGENCY U. Ihereby wirshnn pecondi isaco(S,v. 30 lending agency for performance of U. F the work for which bis permit is issued (Sec. 3(199, Cl, C.) Q U Leader', Name } LcndefAddress I rmii,i I cenee that I have with this application and site the the sMwc information to 7) Val U zcome(. l agree m comply with all city and mpmo ntativneea and state luwm7`up n and QTY. aloe arennxwniogandh ins authonmreeocs. fives of this city to enter upon the uM,ve-(We) nedagree nowayroperry forImnity an keep cs. (We) agree m, save. indemnity and keep harmless be City of Cupertino against in consequence ceof costs and expense which may in any way accrue against said City mICA of UNDERSTANDS StANDWIL SOURCE RHGUNDERSTANUS AND WILL COMPLY WITH ALL NON -POINT SOURCE RIiGULA'TIONS. Signature of Appli,mr/Comidemr Date HAZARDOUS MATERIALS DISCLOSURE, Will the applicant or future building occupant store or handle ha,n odou, material as ball nal by the Cupenino Municipal Code, Chapter 9,12, and the Health and Safely Code, Seen i 2553200! ❑Yes ONo Will the applicant or future building occupant use equipment or devices which emit horzolous air contaminants as defined by the Bay Area Air Quality Management District? 0Ycx C] No 1 have read dm hoazrdou, materials requirements under Chapter 6,95 of the Culi- fomia Health & Safety Code, Section. 25505. 25533 and 25534. 1 undersand that if me building does not currently have atenant, that it is my msponsibility in notify the occupant ,,find ralninments which toes, he met poor,, iswanec of a CenfOcatc at Occupancy. PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS OVER 100)AMPS SIGNS ELECTRICAL. SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE [NST. POWER DEVICES SWIMMING POOL FLECT'RIC OUTLETS—SWITCHES—FIXTURES NEW RESIDENTIAL ELECTR SQ PLUMBING PERMIT I FEE PERMIT ISSUANCE�� AL'I'EK—DRAP&yggCN MATE BACK FLO.pW� PROTIiCT F)�V � x DRAINS ,AR OND. FIXTUR``ES11—I'ERT'RAP t{IVsi GAS—&1.5 S M -I INCA OlTl'LI:FS GASB— EA.SYSTEM-OVER 4 (EA) GREASEANDUSTRL WAS 117 [SHERCEProK GREASETRAP SEWER—SANITARY—STORM EA. 200 FT, WATER HEATER W/VENT/ELECT R WATER SYSTEM/FRPTING WATER SERVICE NEW RESIDENTIAL. PLMB. SQ, IT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10.000 CFM) AIR HANDLING UNI f (OVER 10,000 CFM) EXHAUST HOOD(W/DUCT) HEATING UNIT (TO 100A00 BTU) HEATING UNI')' (OVER I(N11XN1 BTU) VENTILATION FAN (SINGLE RESIU) BOILER —COMP (3HP OR 100,000 BTU) BOILER —COMP (OVER 100,000 B'fU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ, FT, JOB DESCRIPTION RESIDENTIAL, SEISMICFEE ❑SFDWL SANITARY NO. APPLICATION SUBMITTAL 11 ❑MULTI -UNIT ❑STRUC'FORAI. NIC C1 INTERIOR CONTROL# IMPROVEMENT C)SWIMMING POOLS ❑ BATH REMODEUREPAIR 0DEMOLITION I] OTHER BUILDING PERMIT INTO BLDG I,LEC'I PLUMB NIECI COMMERCIAL: JOB DESCRIPTION RESIDENTIAL, SEISMICFEE ❑SFDWL ❑ KITCHEN REMODEL []ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUC'FORAI. MODIFICATION C1 INTERIOR (] CHIMNEY REPAIR IMPROVEMENT C)SWIMMING POOLS ❑ BATH REMODEUREPAIR 0DEMOLITION I] OTHER COMMERCIAL: ❑ NEW BLDG/ADDITION ❑ DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER Li SQ. FT FLOOR AHG\ I $ISQ. FT VALUATION 6© BUILDING DIVISION (ELS PLANCHECK FLIT ENERGY FGII GRADING FEE SOILS EL' PAID Date Re,bpl # TOTAL: FEE BUILDING FEE SEISMICFEE 'V ELECTRIC PER PLUMBING IEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FlrH PAID Dale Receipt # ISSUED e / VBYr / VBY: OFFICE