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S 2639APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY _ CITY OP CUPI']RTINO BUB.DINr. - ELCCIRIGL ITRAM I NO. ItU1LDINC DIVISION APPLICATION/PERMIT .., „ I'um ......—n v ocu ,e ".I S 2639 PHONE: es �Ur`Uty Rs7 1 herby affirm item 1 tan Inconsiderate, meii,mm, of Chapter 9 (commencing yC,Z with Section 7000) of Division 3 of the Business and Professions Code. and my lit ca is Y u'F in full line, and efecl. Urh Liccnsc Class hicp ❑ Consultant Fecs Paid by Applicant (Initial) )TY EI-ECI'RIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENT [A]. ARCH] 1'IiC'I"'S DECLARATION z C,N z I understand my pluns.•holl he used as public records OZ Literwri Podesiomf a GG�J ( MER BUILDIiR DFCLARAUON algaIyl1¢ Ih-ly II' Ilo,I ,tI II C t 'I sI ItwIn, 'he � y U following' (S I" 7031 5 a I I ss ( J: A 'ry orco my t+1'31a,y whin I Pc I I I '11 P dth p' any structure P... I I l :II 'plf tl North 11, II :g dvaement �tyHj y'' mal heslunsed prsua,nt the Pon-d!lu C t err License'Luw(Couple,9 tail �0 �0 @mnnre.....withSectnnl(XXBmI' Divlsimn 3 of IM1e H usiness and Professions Cush) (it L 0. C ohm he is esemmM pl einm send the basis for the alle,od Gumption. Any violation of if �_ LL Semon 1031.5 by any applic:mt fn, a permit subjects the applicant to a civil Penally of m of more than live hundred dollars(SS(M). ❑ Las owner ofthe pmpert,,n:nyerployces with wages as their sole conlpenvtion. p- will do the work. and the suumnr is not intended mothered for sale(See 1(yTBrdness IT W 3 m and Professions Cit'e Comencmr's License Law does not apply to an mortar of 0.property who builds or improves thereon, and who fres such work himself or through his a employees, provided that such improvement, are not intended or offered for sale. If. however, the building (ir insprovement is sold within one Yvaraf completion the rte, -builder will have the Imakn of proving that he did not build or improve for pur- enLsaI ). I, as owner of the property, am exclusively contracting with liceired contractors to sms me, the project (Sec 1HW. Bovines. and Prnfcssian. Code) The Commerce' LIU- nse Law does not apply to an owner of property who builds or improves thereon, and QTY. who eotnrcn for such pmjco with a commctnr(v) licenced P-11..nl r the Cmucteno I License law. ❑ 1 tan exempt under tiro. . B & P C for this reason Owner Doc WORKER'S COM VENSAL'ION DECLARATION I henchy allinn snit,, penally of lcrjury one nfdo f mlltewing d"Iturnin e, ❑ Ihave 1 1will u hair it Ce'lif,ae ul'Corte self -locum hawoders Cmm en sdion, as pnrvidcd liter by Seerion 3900 ul'the Labor Codes for the pcdonnana of the end for which this purnlit Is issued I In... and will nrii lain Wolkcts C .tion Imurunm, as required by Stadion 390X1 A the Lab o Curie, for me Ix'nonnance uI the work for which Blois permit is issued. My Workers Col.lpU satlan lnstn:uau carrier and PolneYnn toner it: Carrier: Policy No.: CIiRI'I1TC, P OF EXEMPTION ITROM WORKERS' CUMI'ENS A] [ON INSURANCE (Thi, wonsword or be completed it he permit is fermate hundred dollars ($ 100) or less.) I certify that in the wri n ource of the work for which this permit is issued 1 shall ma corky any person in any'renncrso as to become subject to the Workers' ComPen- Z satins Lows it California. Dam OO Appucadt Z N NOTICE 10 APPLICANT: 11, after making this Ccnifhcmc of Evempti... you should ?became subject n the Waders Cooperstown provisions of the Labor Code. You must forthwith comply m ith such provisions or this pernia shall be deemed resulted. a� Cawthe. I,. o[ON LENDINGAGENCY U Iherehy off nn lhauherc i>asnmvmniun lending agency for the pedortnana of IL F" IM1e work for which this permit is issued (Sec. 3091, Cie C) 0U London's Name r Lid Lender's Address d 1 certify that I have read this application and state that the above information is F' h coral. I ab'rcc eh annply wish ell city and county nNinanms hind vine laws relining Io QTY. U nuilJing amslmction, vnA nenTy:mthnrim reprcsenulivcs mflhiv city nh enmruPrm IM1e above-In,nlioned prmpeny Int inspection Purposes, (We) agree In save, iadmnnily and keep Irnnless the City of Cupenien against liabilities, taighnenLv, corn and egerses which may in any way accrue against said City an nse,evoleol I, lonung o this perrn0. API'IJCAN IUNDEi ILS PANUS ANO WIL1, COMPLY WITH ALL NON -POINT SOURCE I(I!GUI.A'I'IONS S,rnrre of APPlicnu/CnnTmctnf Dar HAZARDOUS MA'E HRIALS DISCLOSURE Will the applicant of Tonto, huildtag mccupunt store or handle hazardous material its defined by The Cupertino Municipal Code, Chapter 9, 12. and the f{erkh and Safety Colo Seen nn 25532(.)! ❑Yce Will the applicant or future building occupant sex equipment or devices which emit h:vurduun air comnminams us defined by the Bay Arca Air Quality Management Divlrin'! ❑ Yet, I have read t c ha.lous matcri.ls "moverem, We, Chapter 695 of the CWi- fomis Heal, & Safety Code Satinet 25505.25533 and 255311 understand mat if IM1e building does not currently have a tenant, that it is my reNsessibi de Io tetify the occupant of Inueellirtl,hemsohich muahhevnet or or to issuance of v CIA-mme of OvenforneY PANIELS UP DO200AMPS SIGNSELECURICAL SPECIAL CIRCUIT/n11SC. TEMP METER OR MILK INS'r MOWER DEVICES SWIMMING Isi ELECTRIC OUT IA!IS -1W, rI CIIiS - PIX NEW RESIDE IS F1AL EI. EC PLUMBING PERMIT PERMEI' ISSUANCE ALI HR - DRAIN& VEN'P-WATER(EA) HACK PROW PROIPCE DEVICE TRAINS - PLOOR, ROOK AREA, COND. FIX 'I'U R I:S - PER 'I'PAT' GAS -Iib SYSTEM -1 INCA 01111-1715 GAS - Y.A. SYSI ENI.OVER 4 (EN GREASUINDUSI'RL WASE IN'r1iRCEl'I"OR CREASE IRAI' SEWER -SANITARY -sroRM HA. 200 PT WAII:R IIITATGR W/VIiNT/El.l?CI'R SsisTER SYSTI:Mfl'RIiAI'INC, WATER SERVICE NEW RE'SIDELN71AL PLMIL SQ. Fr. AIECI IANICAL PERMIT PHRMI'I ISSUANCE ACfHR OR ADD 10 MECH. AIR I IANDIJNG UNIT ('10 I0,IXX1 CPM) AIR HANDLING UNI 'I'(OVER I00h)CPM1 EXIIAUSI' HOOIl OODUCI ) UEA'l'ING UNIT ('IO IW.00I BTU) [HEA'T'ING UNIT (OVER I(XL(XX) BTU) VENTILAIION PAN (SINGLE RESIO) BOILER -COMP (311POR I(XL(XX)1{TU) BOI LEER - COMP(OVER I(X).o()OHTU) AIR CONDITIONER NEW RESIDENTIAL MEECH, SQ. 1cr FEE SQ� FT. FLOOR AREA I $/SQ. PT ZZ o0C) 2 —1 l NIC, OCC .(TRO CONTROL 4 �((UP BUIL-DIN ,PERMIT INFO FEES BLDG 17LECf ❑ PLUMB NISCH ❑ ❑ FEE )OB DFSCRIPTION RESIDF-NTIAL: ❑ SFUWI, El ADDITION ❑MUI:II-ON11' ❑INTERIOR IMPROVEM171,1'1' ❑ BATH REMODE1 jRE'Allj ❑..I'HI?H �✓✓ T/Q ❑ KITCHIiN REMODEL [D PLUMBING RE PIPIT ❑ S'I'RUCI'ORA[. MODIIICA'UON ❑ Cl I ISINEY REPAIR E)SWIMMING TOOLS DIiM( 1. PION V Rcccipt N ' is Z TOTAL: COMMERCIAL'. ❑ NEW BLDG/ADDITION ❑TENANT IMPROVEMENT OTHER ❑ DHMOI,11 [ON ❑PZ)S'ERVICE V//yS © FEE / FEE SQ� FT. FLOOR AREA I $/SQ. PT ZZ o0C) SOWEiS 'rYPI: CONS 'IRUC 'I'ION ENERGY ITE OCC .(TRO 34a -AP s\� 4 �((UP BUILDING DIVISION FEES PLANCIICCK ITHE ENERGY ITE GRADING I OILS FEE PAID Date Rcccipt N is Z TOTAL: BUILT G Z6, 17, V//yS © FEE SElsnL :, ELECT CFEI: PLUM ENG 19213 MET NICALVEH C'ONSII C'HON'1'AX LOUSING MI'1'IGA'T ION PE13 PAIR Date Receipt M TA ISSUANCE y_ ISSUEU ItY: DAfI? 4)