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991200054 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN CITY OF CUPERTINO BUILDING - BUILDING DIVISION APPLICATION/PERMIT PLUMBING- nrnr rsne" annus 2 - NAME. NAME. 3 J ElConsultant Fees Paid by Applicant (Initial) I It— — 3rLoo— C 1 z L4 LICENSED CONTRACTOR'S DECLARATION I QpY 1 hereby affirm that 1 am licensed under previsions of Chapter 9 (e omen Icing M�Z with Section 7001Bof Division 3 ofthe Business and Professions Code,nnd my license is in full force and effete. Q UZ U License Class Lic. M 6 i Dam comrachm co HITE 46hhRATt�IQ--' ~ h Z_ I .,,it nJ as public rswords Ham, W Licensed ,...11 that I n exempt fr DECLARATION 1 hereby affirm (lite I am exempt from the Contractors License Law for the aU following reason (Section 7031.9. Business andtem Cume: Any city or County I+1 W O y which minlrca a permit m enn.aruch alter, improve, de demolish, or repair any swdnrc prior to it, issuanc,. i loo requires the applicant for such permirto fie a signed smtemem } that he is licensed pursuanno the provisions of the Commands License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Businaes and Pro(ewi.ns CMO or d y a e1 0,m he is Cxempt tnerefrom and the oasis for the alleged exmophoa Arty vlolannn nr W -sn Section 7031.5 by any applicant for a permit subject., the opplietch to a civil penalty at t more than five hundred dollars ($510). =G D I, as owner of the properly, or my employees with wages as their who compensation, will do the work, and d em.....m Is not Intended nr offered on,ale (Sec.7 WL Business W m and Professions CiAc: The Contractor's License law does not apply to an owner of 6'3 property who bond,,,, impmvcs their.., and who does such work hurt elf or through his own employees, provided (lint such improvements are not intended nr offered fir sale. If, however, the building or improven nt, Is mid within ane year nllamtpleti.n, the onmer-builder, will have the human of proving that he did out build or improve for pur- pose of sale.). 1, as owner of the property, am exclusively contracting with licensed con(mnors m usmsruet he project (Sec. 7194, Business and Profe,sinas Cole:) The Conrumor's Li - se Law does not apply to an owner of pmpeny who build or improves thereon, and QTY. whoamructs for such projects with u cmaracmgs) licensed purnmand to the C.nmmmr's LieenseI... 1 am exempt under Se. ,1{ & P C far this reason Date mer WORKERS COMPENSATION DECLARXI'ION 1 hereby uffirn under penalty of perjury, one of the following declarations. ❑ [have and will maintain a Certificate of Consent o self-insum for Workers Cout sato.., as la vided for by S, ,ion 3700 of the Lthor Code, for the pe brmu he of that wofk for which this permit is ismed. El 1 have and will maintain Workers Compensation Ins.mnee, as required by Section 37M of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance curler and Policy number aro: Carie,, Policy No.: CP.RI'IFICATE OF EXEMPTION FROM WORKERS' COMPLsssriON INSURANCE finis section need not be compleled if Ne permit is fur tine hundred dollars Sl 00) orle,c) I certify that in the perfarmance ofthe work forwhich this permit is issued, l shall not employ any Person in any irunner so as to beenmu subject to the WorkersCompen- z cation Laws of California. Dmc ZO Applicant t NOTICE'1'O APPLICANT: IL after making this Cenilicme of Exemption, you should become vAncil It, (he WorkC's Compemnlion pookions of the Labor Calc, y...ve( forthwith comply with such provisions or this Permit shall be deemed revoked. 0 CONSTRUCTION LENDING AGENCY U 0 I hereby affirm met hen is a Conswction lending agency for the puffnimannm of LS.— the work for which this permit is issued (Sec. 3097, Civ. C.) OULender's Name W Lender's Address 1 eenify that 1 have read this application and nate dint the above infitmullon is N correct. I agree m comply with all city and county ordinances and state laws relating to U building constriction, and hereby authorize representatives ofthis city to cater upon the above-mentioned property lir inspection purposes. (We) agree to saw, indemnify and keep harmless the City of Cupmino against Imbilities,judgmenq costs and expenses which may in any way acetne against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH A 1. N N-I'OIIN SOURCE NEGUI.ATION. �� Signature of App acnn Dat HAZARDOUS MATERIALS DISCLOSU E Will the npf li,ent er (more building wCap:mt score it handle lima dman material as defined by the Cupeninn Municipal Code, Cbupter 9.12, and the IIcahn and Safety Code, Section 25532(a)? ❑Yes E] No Will the applicant or future building occupant use equipment or devices which mit huardeus air csmmml.ants as defined by the Bay Area Air Quality Management District? ❑Yes 0 N 1 have read the hazardous materials renuirements under Chapter 6.95 of the Cali- fomiu I Icalth & Safety Code, Sections 255115, 25533 and 25594.1 understand that if the building dues no( Currently has on. I t it is my resph.111I (o ti fy theoccupunt of The reqiremnt ues whir a be met P' t. issuuncep(a i u pancy. ELECTRIC PERMIT I' FEIi PERM H' ISSUANCE APPLIANCES - RESIDENTIAL PANELS UPT0200AMPS 201-1000 AMPS OVER IIXX)AMPS SIGNS I:I.ECTRICAL SPECIAL. CIRCOIT/MISC. TEMR METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC ou-n-n S-SWi PcHES- FIXTURPS NEW RESIDENTIAL ELF,CPR SQ FE PLUMBING PERMIT PERMITISSUANCE ALTER - DRAIN & VENIT- WATER IEA) BACK FLOW PROTECT DEVICE DRAINS- FLOOR, ROOF, AREA, COND. FIXS'URF.S - PER TRAP GAS - EA. SYSTEM -1 INC. 4 OUTLETS GAS FA. SYS'I EM -OVER 4(EA) GREASFANDOS'TRL WASTE INTURICEPTOR 2010 FT AIR HANDLI Bflt HANDLING UNIT(OVER Io,IXO CFM) EXHAUST HOOD(W/DUCT) HEAPING UNIT (TO 100,000 BTU) HEA'T'ING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER -COMP (3HP OR 100]00 BTU) BOILER -CGMP (OVER 100," BTU) AIR CONDITIONER NEW RESIDENTIAL MECIL SQ. FT OFFICE JOB DESCRIPTION RESIDENTIAL: 11211\ ❑SFDWL N/C ❑ 9 //._CONT tOL e l0 ❑ PLUMBING RE PIPE Bl11LDING PERMIT' INFO ❑STRUCTURAL 1{4 0 FLECI' PLUMB MUCH JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL []ADDITION ❑ PLUMBING RE PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIvicai ON El INTERIOR El CHIMNEY REPAIR IMPROVEMENT [ISWIMMING POOLS ❑ HSI II REMODEUREPAIR ❑ DF.M01.1'f[ON ❑ OTHER COMMERCIAL NEWBLD(1)D ❑DEMOLITION El TENANT ❑ FOOD SERVICE IMPROVEMENT ❑O'f1IER SQ FT. FLOORARHA VSQ. EU ITE G VALUATION STORIES TYPECONSTRUCUON OCC. GROUP APN BUILDING DIVISION FELS _ PLANCHECK FEE ENERGY FEE GRADING Fido IteLS FEE PAID Dam Receipt TOTAL: BUILDING I71717. — FEE SEISMIC FEE ELECI RIC FEE PLUMBING FEE iCHANICAL ITE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Dam Receipt M TOTAL: ISSUANCE DATE z /-- gs