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28525APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'- USE BALL POINT PEN ONLY CITY OF CUPERTINO ntarComx.-nr.n t.a nnx,na. I •-•-•..-...-. 28 ^gam ^ BUII,DING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL. -/8 CONTACT: ,,% R_ PHONE S�IiJWa &AASST&�i 9CJv_z�� ❑ Consultant Fees Paid by Applicant (Initial) 1 henchy affirm that 1 am licensed under provisions of Chapter 9 (etenmencing yoy1isZ with Section 7") of Division 3 ofem Business and Professions Cal, and my license is FSS in full force and effect. V OF License Class Lie. is Data Cammcmr F=N ARCHITECPS DECLARATION O Z:]� YPlana shn cou Y OWNER -BUILDER DECLARATION C I hereby affirm that 1 are exempt from the Cmurarmes License law for the CLU following reason. (Section ]0315, Business and Pooessions Code: Any city ur county LL, WF which re ptims a permit to construct, alter, improve, demolish, nr repair any structure rrrFF-F��y priorm its imuance, also requires the applicant for such Permit to file a signed statement F, aO that he is licensed pursuant o the provisions ofthe Commences License Law(ChapmT9 15D y (commencing with Sectioo 70000ofDivision3nfine Businessand Pofeeme, Core)Or d op LL fl ut he is exempt therefrom and the basis for the alleged exemption. Any violation of N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of t mutation five hundred dollars (5500). �Q ❑ I, as owner of the property, or my employees with wages tis their sole compensation, will do the work, and the sounure isnot intended or mlend for sale (Sec. 7044, Business ad 3 and Professions Code: The Contractors License Law does not apply to an owner of .. property who builds or improves the... end who does such work himself or through his we mnpbyees, provided that such impmvementn arc not intended Or offered for sale. if, however, the building or improvement is sold within one yearofcompletion, the owner -builder will have the burden of proving that he did not build or improve for pur- pose oxide.). ❑ L as owner of the property, um exclusively nmwnin, with licensed conoacons to construct the Iaoject (See 7044, Business and proucoinm CM,,)'I'he Contmcmev Li - came Law does not apply to an owner of property who builds or improves thereon, and QTY. who contracts for such projects with a contracmrod licensed pureuautto the Contractors License Law. ❑ I am exempt under Sec. ,H&PC for this reason Owner Dam WORKER'S COM PENSAI'[ON DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have amt will maintain a Certificam of Comenuo selMmure for Worker's Compen- sation, as provided for by Section 37M of the Labor Cale, for the performance of the work for which this permit is issued, ❑ 1 have and will maintain Workers Compensation Insurance, as required by Section 37W of dee labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: (This section rte not lu completed if the pemtit is forone hundred Je m($IW) or less.) ictally that in e--ormanm of tlwark to which this permit is iso .l shall not employ any Per i " n: u c mbjcct to the Workers' Compm z eation Laws n(Cali on C) Q Applicant Z NOTICE TO AP IC LeOcr rn�lhix�. ti f rg)}IIOn,; youhauld f't become suh'ect the Worker's Com_pb'j tr q�f, Rite L h'rS}rod mum forthwith core with such Pmvlulnnsm Penna hu cJc revs CONSTRUCTION LENDI ' CY U 0 Ihereb ffirmthat there isacon, nlending agency for the performance of the work for who this permit'' I Sre. 309], Civ. CJ O U Lenders Name Lenders Address I certify that I have real this application and state that the above information is H comer I mum comply with all city and county ordinances and Into law, relating to QTY. U ,z, building construction, and hereby outhorizempresentatives alibis city menders'. the above-mcmioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilitiev, ludgm costs and expenses which may in tiny way umme against said City in mmequen t11pt�1�nGng nft�s permit. APPLIC Sarft TANDS AC�RRCT7JiTLT5YITN ALL NON -POINT Will the applicant or future building occupant store or hAdle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532m)P `' C] Yea AN. Will the applicant or future building occupant use equipment Or devices which emit haaadou. air contaminants as defined by the Bay Ana Air Quality Management District! El Yes )CN. 1 have mad the ha vdnm mamriuls rtquireme to under Chapter 6.95 of the Cali- fornia Health ItAm asCudgfections 2 33 and25534.1 understand that if the ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANELS UPT0201JAMPS SIGNS ELECTRICAL. SPECIAL CIRCUITRAISC. TEMP METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC 'OUTLETS-SWITCHES-FUCTUkES V` NEW RESIDENTIAL ELECTR SQ Fr. PLUMBING PERMIT PERMIT ISSUANCE ALTER- DRAIN & VENT- WATER (EAI BACK FLOW PROTECT. DEVICE DRAINS - FLOOR• ROUE AREA, COND. FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OUTLETS GAS - EA. SYSTEM -OVER 4(EA) GREASE/INDUSTRL WASTE INIERCEPTOR OR BASE TRAP SEWER -SANITARY- STORM BA. 200 FT. WATER HEATER WNENT/ELECI'R WATER SYSTEMI RFATING WATER SERVICE NEW RESIDENTIAL PCMB. SQ. FT. MECHANICALPERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH, AIR HANDLING UNIT (TO IE0110 CFM) AIR HANDLING UNIT (OVER IRDX) CFM) EXHAUST HOUR) W/DUCT) (MATING UNIT(TO I00,00B BTIB HEATING UNIT (OVER 100,003 BTU) VENTILATION PAN (SINGLE RES ID) BOILER - COMP (3HP OR 100,000 BTU) BOILER- COST (OVER I00,0g1 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE I— FEE FEE COMMERCIAL• ❑ W BLDG/ ADDITION ❑ DEMOLITION F.NANT ❑ FOOD SERVICE ROVEMFNT ❑ OTHER 1-70-4t �/ SQ. PT. FLOOR AREA al .!'saw$$//SSQ. FF f {�� l+J STORIES11 TYPEC PLANCHECK FEE ENERGY FEE GRADING IM PAID a _ Dem Receipt 0 TOTAL: BUILDING FE SEISMIC FE ELECTRIC IE r• PLUMBING JER CONSTRUCf10NTA HOUSING MITIGATION PAID Dam Receipt TOTAL: tH l IDU . - ISSUANCE DATE ISSUED BY: -1yL ED FEE JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEUREPAIR ❑ DEMOLITION ❑OTHER I— FEE FEE COMMERCIAL• ❑ W BLDG/ ADDITION ❑ DEMOLITION F.NANT ❑ FOOD SERVICE ROVEMFNT ❑ OTHER 1-70-4t �/ SQ. PT. FLOOR AREA al .!'saw$$//SSQ. FF f {�� l+J STORIES11 TYPEC PLANCHECK FEE ENERGY FEE GRADING IM PAID a _ Dem Receipt 0 TOTAL: BUILDING FE SEISMIC FE ELECTRIC IE r• PLUMBING JER CONSTRUCf10NTA HOUSING MITIGATION PAID Dam Receipt TOTAL: tH l IDU . - ISSUANCE DATE ISSUED BY: