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29589APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO 47 -• BUILDING -ELECR BUILDING DIVISION APPLICA'1'IONPERMIT PLUMBING -MECHA BUILDING PROJECT IDFY to 0i LIC 4:i4P,ry0 s�l 1 6'L E:1 Consultant Files Paid 6y Applicant (Initial) I hereby affirm Nm 1 am licensed under and Pruuns ofs Code, 9 (commencing with Section ande)of Division 3al the Business anal Professions Code, and my license is ' in full force and effu't. Date Claw Llc.# 1 arc Coulonem, AalTEeS DECLARATION 1 understand my planss shall be used as public records Licensed Farm aslnm.I OWNER -BUILDER DECLARATION 1 hereby alfirm that 1 am exempt from the Contractor's License Law for the following mama (Section 7031.5, Business and Professions Coale: Any city or county which rclaims u permit to comiroct, alter, improve, demolish, or repair any stmcmte prior to iu issuance, also requires the applicant for such perm L to rile a signed statement that he is licensed pursuant to the provisions of the Commences License Law (Chap1119 (, ommeming with Section 700 of Divbin i 3 ol'thc Boniness and Professions Code) ar that he is exempt Ihcrefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mom than five hundred dollars ($501). I, as owner of the property, or my employees with wages as their sale compensation. will Ju the work, and the stmcmre is not intended or offered for sale (See. 7044, Boniness and Professions Cede: The Contractor's License law J«s net apply m an owner of property who builds or improves thereon, and who does such work himself or through his own nnploylms, presided that such improvements ore not intended or offered far sale If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving than he did not build or improve for pur- pnse of art.). ❑ 1, as owner of the papery, am exclusively contracting with licensed contmcmrs m mnmet the majoa (Sm. TIWq Business and Profeainns Colic#The Contractor's Li- ceamLawdoesnolapplytoanownerofpropcnywhohuildsorimprovestheater.and QTY, who contracts for such projects with a contmctor(s) licensed pursuant to the ContmetnJs License Law. vm exempt under Sec. . B & P C for Nis reams Owner Date . WORKER'S COMP Ii SAT10N DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: I have vnd will mainmin n Ceniticam of Consent to vdGimurc for Worker's Compue. snion, as provided for by Section 37M of the Labor Call for the performawe of the work for which this peroul is issued. 1 have and will maintain Workers Conspcnwtian In unnce, as required by Section 370u of the Lab, Gyle, for the performance of the work for which this permit is issued. My Worker's Compcnnatlon Insurance carrier and Policy number arc: Cameo Policy No.: CIiRTI FICATE UI' EXEMPTION FROM WOR KERS' COMPENSA PION INSURANCE Gbis section teed net be completed iOhm room is far one hundred dollars ISI W) or less) I sanity that in the performance ofthe work for which this permit is issued.I shall not employ any penton in any manner so as to become subject n the Workers' Compen- ,Z onion laws of California. Date O Applicant .N. NOTICE TO APPLICANIL If. after nmki ng this Certificate of Exemption you should Fw ! become subject to the Worker's Compensation provisions of the Labor Cade, you must tali forthwith comply with such provisions or this Permit shall N• deeme l revoked. CONSTRUCTION LENDING AGENCY UQ I hereby affirm that there is a construction lending agency for the performance of F Ihewtalk lo, which this Permit in issued (Set. 3097. Cim C.) U Landers Name rWLender's Address CL. 1 certify that 1 have read this application and slam that the above information is nFi N correct. I agree to comply with all city and county ordinances and state laws relating to QTY. L)Z building consrnmem, and hereby cathodic representatives of this city to enter spm the above-mentioned property for inspection purposes. (We)agmento save, indemnifyes keephannlens the accrue adCitl in a.itiesjualgmenheu.a and expenses which may in any way acerae against void City in conscq NT of the granting S Nis p WILL AI'PI ANT UNDERSTANDS AND WILL COMPLY WITH ALL N POINT SOI' sC :GULA . S. /a l Signature of AppiicantlCo rxmr (•/� au If tIDUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle harurdaus material as defined by the Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety Cafe, tech.... 25532(1)1 ❑Yes Fl No Will the appllcanl or ILme, building occapen use cynipmcm or devices whicM1 -ANt hazardous air con timm me as defined by the Huy An Air Quality Management ❑Yes Fl No I have read the hvnrdons materials rcyuiremems under Chapter fi 95 of the Cali hsmia Health & Safety Cana, Sections 25505, 25533 and 25534.1 undersand that if the building does not currently have a tenant, flue n is my tcs of ibiliry to notify the occupant of the requirements which must be Fuel prior to issuance of a Cenificam of Occupancy. ELECTRIC PERMIT FEE PERMIT ISSUANCE •C" APPLIANCES — RESIDENTIAL PANELS UPTOYOUAMPS 301 -Shat MP5 OVER 1000AMPS SIGNS ELECTRICAL. SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS—SWITCHES—FIXTURES NEW RESIDENTIAL ELECTR SQ 19'. PLUMBING PERMIT PERMIT ISSUANCE ALT17R— DRAIN & VENT— WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS — BOOR, BOOB AREA, COND, FIXTURES — PER TRAP GAS — EA. SYSTEM -1 INC.4 OUTLETS GAS— EA. SYSTEM -OVER 4 (EA) GREASF/INDUSTRL WASTE IN'FERCF-PTOR SEWER — SANITARY — STORM E1. 200 I1'. WAS SIR HEATER WIVEN r/ELEQI'R WATER SYSTEMRREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. PC MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD 10 MI.CH. AIR HANDLING UNIT (TO 10.000 CPM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT l0 10(frfNl BTU) HEATING UNIT (OVER 100.000 BTU) VENTILATION PAN (SINGLE RTSID) HOI LER —COM I' QHP OR 1 W,000 67U BOILER—COMP(OVER IOnfu BTU) AIR CONDITIONER NEW RESIDF.NI'IAL MECH. SQ. FT OFFICE - 29589 .NITARY NO. APPLICATION SUBMITTAL DATE NIC CONFROLM ID BUILDING PERMIT INFO NL 'Is PLUMB h1ECH De� JOB Ise W1. ❑ KITCHEN REMODEL ADDITION ❑PLUMBING RE -PIPE MULTI -UNIT ❑ STRUCTURAL MODIFICATION [:1 INTERIOR ❑CHIMNEY RI?PAIR I.VIPROVINEN'r ❑ BATH REMODF.VREPAIR ❑DEMOLITION ❑ OTHER ❑ DEMOLITION ❑ FOOD SERVICE SQ, Pr. FLOOR AREA NSQ. Fr. 11 35 i t 'J:3 FEE 31v� VALUATION z q5 STORIES - TYPE CONS '1'RUM HON JUL 021 OCC. GROUP APN CITY Ur UUYLI t 1 BUILDING DIVISION FEES PLANCHECK FEE 4 ao kY�2 ENERGY FEE 26a � GRADING FEE SOLI S FEE PAID Date Receipt # TOTAL: w BUILDING FEE FEE SEISMIC FEE ELECIT IC FEE �1 PLUMBING FEC MECHANICAL FTI: Won Ij CONSTRUCTION TAX HOUSING MITIGATION IEE PAID Date Receipt# TOTAL: ISSUANCE DATE 1,W ISSUED BY: _|/§/ n | ¥!@® _ \ \ g /-__- ' #0)() ,! 7 4 / \ \� ' ` | \ (� () / \ ,f z ! s= : [§ ©° 2 k ! a | 1 . \ to o : $ | m r)2 , | z 0 » |� §m § \ \ (kmsƒ z i § ; / ! \\\ ' j E �- _ f , r \�\ _ c m | | § - S '° \ mlio _|/§/ | \ g /-__- ' _§// \ ' ` / \ ©° § k \gym . to o E` w m r)2 , | » §m § \ \ (kmsƒ i § ; / ! \\\ ' E f , r c ° | ( § - S '° \ > - ��P ./I ( ; k / ■ (\) _ *!/ 2 : : , ] n '00 go' j g) mo m bb | 7 M r, (\ r r § �)\ wl 0)/ ; w ■ W. °m |0 ; \ | R \