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30067APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - !YI BUILDING DIVISION APPLICATION/PERMIT Y, HAZARDOUS MATERIALS DISCLOSURE Will Ne applicant or future building occupant store or handle hazardous material in defined by Ne Cupertino Municipal Code, Chapter 912, and the Health and Safety Code. Section 25532(a)7 OYes ON. t Will the applicant or From building occupant use equipment at devices which chair hicar dmu it contaminants as defined by Ne Ray Area Air Quality Management Diva ro ❑Yea 0 N I have orad rte havmdOns metedoH requimmemx under Chapter 6.95 of she Cali - humin Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building dues not currently have a ream, that it is my responsibility to notify Ne oecupuns of the requirements which must be mer prior to issuance of m Certificate of Occupancy. Owner or authodud agent Dare E BALL POINT'PEN ONLY RUILHNG. ELECTRICAL. PLUMIIING - MECHANICAL RUI LDING PROD NC'1' IDEN'DFICATItIN Iory FiE: -4SIGH_ "Cq9 6E s's Consultant Fees Paid by Applicant (Initial _ ELECTRIC PERMIT _FEE PERMIT ISSUANCE' APPLIANCES — RESIDENTIAL PANELS UP10 2W AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICLS SWIMMING 1,001. ELECTRIC OUTLETS — S W 13'CHES — PIXTURLS NEW RESIDENTIAL. ELECTR PLUMBING P13RMIT PERMIT ISSUANCH TCR - DRAIN Sc VENT- WATER IEA) I3A FLOW PROTECT. DEVICE DRAINS LOOIL RODE, AREA. COND. FIXTURES -1 'TRAP GAS -EA. SYST13 I INC.401 GAS - EA. SYSTEM -0 R4(1. CItEASI%INDUSq'RI. WAST ORhASf?'TRN' S13W1?li—SANI'I'Nt S30RM WATER IIEAI'i? IVI?N'1'/I:LE WAI'lili SV ' IiM/fR13ATIN0 MECHANICAL. PERMIT "V 30067 NITARY NO. APPLICATION SUBMITTAL DATE NIC CONT�/ROO�' L# ❑ V BUILDING PERMIT INFO 31.DGI_ PLUMB MECH tKI JOB DESCRIPTION CONTACT. V PHONE:: f ❑SFDWL �ER�Y tA//i—*Mjq ( 10737-3910 X HOZ 1-00in U V to LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 an licensed under provisions of Chapter 9 (commencing with Section 7") of Division 3 of Ne Businessand Prof,epssiNons Code, andmy license is full force and effect.�AS iAOVOq License Class /1 Lic. # / O 7 -Date Contractor QTY ' MODIFICATION ret Z FO N Z OZ=a ARCHITECTS DECLARATION 1 understand my plans shall be used as public records IMPROVEMENT F 4 F W I X :y aE O ud U 1+13 LL I"' O fly W�00 L S C Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 7031.5. Business unit Professions Cade: Any city or .only which requires is Form to cumtrum, alcor, improve, demolish, or repair any smcmre prior to its issuance, also requires the applicantfor such perming file a signed statement that he is licensed pursaanuo the provisions of the CnnlmcmrN licame Low (Chapter 9 (commencing with Smon.7")ofDisininn3of the Business and Professions Gale) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Seceon 7031.5 by any applicant far a subjects the applicant to o civil of ❑ OTHER STORIES TYPE CONSTRUE NEw4usIDENTIAL MECH. SQ.F.. — y =Q WB:— - L 3.. permit punity not more than five hundred dollars ($500). Ol, as owner of the pmperty, or my employees win wages as their sole compensation, will do Ne work, and Ne structure is not intended oroffered formic (Sm. 7044, Business and Pofesions Code: The Contmmors License Law does not imply m ua owner of pommy who builds or improves thereon, and who does such work himself or through FOR BUILD GDfVISI :ES his awn employees, provided Nat such improvements am not intended or offered for PLANCHECK FEE T' sale. If, however, the building or improvement is sold within one year afcompletion, the GRADING r^ owner -builder will have the burden of proving that he did not build or improve for pus, SOILS FE f sale.). s owner of the property, a xdinve)y conlmcting with licensed contractors In SQ, PT. construct the project (Sec. 7044, Business and Professions CWc:) The Crmlmclm's Li - TOTAL: BUILDING IN L4 , w cerise law does not apply to an owner of property who builds or improves thereon, and QTY, who contracts for such projects with a rontmnor(s) licensed pursuant to the Contractor's License law. 1 em exempt under Sec. . B & P C for this reason Owner UIO WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declunhium: 1 have and will maintain a Cuntfmmc ofConsem to self -insure for Worker's Comment vision, as provided for by Section 37M of the Labor Gale, I'or the perlinmance of the work for which this permit is issued. ❑ I have'and will maintain Workers Compensation Insurance, as required by Section 37M of she Lobar Code, for the perfermunce ol'tbe work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carrier: Policy No,: CERTIFICATE OF Ii EMPTION FROM WOR KERS' COMPENSATION INSURANC17 alisscam. need not hecnmmlemd if due Per it is lir one hi dreddolle,6100) orless.) I certify that in the performance ol'the work fur which Ilik permit's issued, I shall Z nos employ any person in any manner nu as to heroine odhoict In Lha Workers' Comgetr nation Laws of California. Date O O h f•+ �+ Applicant NOTICE TO APPLICANT: If, afire( making this Cedi licute of Exemption, you ehook become subject to the WorkrA Compem alien provisions or the Labor Code, you Innst wA U O W O ULender's W 11rr an F V U forthwith comply with such provisions or this Permit dual l he deemed mvokchl, , CONSTRUCTION LENDING AGENCY I hereby uffimuhatthem is a construction lending agency for lheperfmm�ince of the work for which this permit is issued (Sec. 3097, Civ. C.) Name Lender's Address 1 certify that I have real this iippllcotlon and steno that she above or nation is correct. 1 agree to comply with all city and county oMtmnces and state laws refining to building construction, and hereby muthorse representatives ofrhis city to enter upon the QTY, above-mentioned limped for inspection purposes, (We) ugrec to save. Indemnify and keep harmless the Col of Cupemino ugulnn liabilities,judgmenss,costs and expenses which may in any way nccmc aguinss.nnW City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. HAZARDOUS MATERIALS DISCLOSURE Will Ne applicant or future building occupant store or handle hazardous material in defined by Ne Cupertino Municipal Code, Chapter 912, and the Health and Safety Code. Section 25532(a)7 OYes ON. t Will the applicant or From building occupant use equipment at devices which chair hicar dmu it contaminants as defined by Ne Ray Area Air Quality Management Diva ro ❑Yea 0 N I have orad rte havmdOns metedoH requimmemx under Chapter 6.95 of she Cali - humin Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building dues not currently have a ream, that it is my responsibility to notify Ne oecupuns of the requirements which must be mer prior to issuance of m Certificate of Occupancy. Owner or authodud agent Dare E BALL POINT'PEN ONLY RUILHNG. ELECTRICAL. PLUMIIING - MECHANICAL RUI LDING PROD NC'1' IDEN'DFICATItIN Iory FiE: -4SIGH_ "Cq9 6E s's Consultant Fees Paid by Applicant (Initial _ ELECTRIC PERMIT _FEE PERMIT ISSUANCE' APPLIANCES — RESIDENTIAL PANELS UP10 2W AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICLS SWIMMING 1,001. ELECTRIC OUTLETS — S W 13'CHES — PIXTURLS NEW RESIDENTIAL. ELECTR PLUMBING P13RMIT PERMIT ISSUANCH TCR - DRAIN Sc VENT- WATER IEA) I3A FLOW PROTECT. DEVICE DRAINS LOOIL RODE, AREA. COND. FIXTURES -1 'TRAP GAS -EA. SYST13 I INC.401 GAS - EA. SYSTEM -0 R4(1. CItEASI%INDUSq'RI. WAST ORhASf?'TRN' S13W1?li—SANI'I'Nt S30RM WATER IIEAI'i? IVI?N'1'/I:LE WAI'lili SV ' IiM/fR13ATIN0 MECHANICAL. PERMIT "V 30067 NITARY NO. APPLICATION SUBMITTAL DATE NIC CONT�/ROO�' L# ❑ V BUILDING PERMIT INFO 31.DGI_ PLUMB MECH tKI JOB DESCRIPTION RESIDENTIAL• AIR# DLING UNIT ('1010.000 CFM) ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION ❑PLUMBING RF. -PIPE ❑MULTI -UNIT OSTRUCfURAL ' MODIFICATION O INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT BOILER—COMP(3 OR100,000RT ❑ BATH RFMODEL/REPAIR 0DEMOLITION ❑ OTHER STORIES A ER OR ADD TO MECH. 1:PLf1MBIN ;W BLDG/ADDITION ODEMOLITION El TENANT ❑ FOOD SERVICE IMPROVEMENT _ ❑ OTHER AIR# DLING UNIT ('1010.000 CFM) MECHANICAL AIR HANOI. G UNIT (OVER 10,000 CFM) CONSTRUCTION TA SQ Fr. HOUSING MITIGATIO FEE . FT. FLOOR AREA JUL 16 eco $/SQ. I BEATING UNIT (OVER PaINP11TO PAID FEE Dare R Via # BOILER—COMP(3 OR100,000RT VALUATT Cil4,2%jr-t©D'.0 BOILER—CON (OVER100,00IBLD STORIES TYPE CONSTRUE NEw4usIDENTIAL MECH. SQ.F.. OCC. GROUP APN FOR BUILD GDfVISI :ES PLANCHECK FEE T' ENERGY PEE GRADING r^ SOILS FE PAID, Date Receipt # ' SQ, PT. TOTAL: - -' TOTAL: BUILDING IN L4 , w FEE ____1A A ER OR ADD TO MECH. 1:PLf1MBIN E'Ch1JIYI1 AIR# DLING UNIT ('1010.000 CFM) MECHANICAL AIR HANOI. G UNIT (OVER 10,000 CFM) CONSTRUCTION TA I.XHAUSTHOO W/DUCf) HOUSING MITIGATIO FEE HEATING ON[ 'POG 1 BTU) BEATING UNIT (OVER PaINP11TO PAID VENTILATIONPAN(SIN .?RP_ ) Dare R Via # BOILER—COMP(3 OR100,000RT TOTAL: BOILER—CON (OVER100,00IBLD AIRCON TONER ISSUANCE DATE NEw4usIDENTIAL MECH. SQ.F.. OFFICE ISSUED BY: