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286204PPLICANT TO FILL IN CITY OF CUPERTINO LINES • USE BALL POINT PEN ONLY BUILDING - ELECTR APPLICATION/PERMIT: VPR PHONE: 4 bS - 3237 LIC NO: 7A) 4t�r_44'l-6Zo I hereby affirm Not I em licensed under provisions of Chapter 9 (commencing r es WC with Seemed? 10) of Division 3 ofthe Business and Professions Code, and my license is in full force and effect `� U pp License Lic. N" 47 Dale Contractor ARCHITECTS DECLARATION 7 so p y 7J I understand my plans shall be used as public records Z WLicensed Professional .•..�4l OWNER -BUILDER DECLARATION 6 1 hereM1y etTum that I am exempt from the Cdntrav'tor's License Law fur the 4 U following remain. (Section ]031.5, Business and Rnfessums Code: Any city or county WO ^ which requires a permit to conswcL eher,�improve, demolish, or repair any structure - h Ja prior to its issuance, also requires lheapplicantfor such permit to file a signed sumosed, Y that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapmr9 00 (commencing with Section 7") of Division 3 ofthe Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of TING L4� Section 9031.5 by any applicant for a permit subjects the applieam to a civil penalty of z y not mora Nen It hundred dollars ($5007. Q❑ I, es owner of Uepropeny, or my employees with wages as their sole compensation, will do the walk, and the shout ure isnot intended or offered forsale (Sec. ]M4, Business and Professions Code: The Contractor's License Law does not epplY to nn owner of Q' .. property who builds or improves thereon, and who does such work himself ar Ihmugh his own employees, provided that such improvements are not intended ar offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for par. pose of sale.). D 1, as owner of the property, ma exclusively contacting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Counselor's Li- cense Law dms not apply to an owner of property who builds or improves thereon, and QT'y who contracts for such projects with a connectors) licensed pursuant o the Contractors ,License Law. ❑ 1 ant exempt under Sec. B & P C for this reason. Owner Data WORKER'S COMPENSATION DECLARATION t I hereby affirm under penalty ofpequry one ofibe following declarations: I have and will maintain a Cenificme ofComent to sol6insure for Wader's Compar- cation, as provided for by Section 3700 of the Labor Code, far the performance of the work for which this permit is issued, have and will maintain Worker's Compensation Insurance, as required by Section 37M ofthe Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are', Carried Policy Na.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE - (This senlon nee l mo he completed ifthe permit is facade hundre4dollars ($100) or less.) I certify Nat in the performanceofthe work far which this Permit is issued, l shall 'not employ any person in any manner so as to become subject a the Workers' Compen- Q z action Laws of California. Data y O Applicant NOTICE TO APPLICANT: If, after making this Ceniticate of Exemption, you should abecome subject to the Worker's Compensation provisions of the Labor Code, you most LQ forthwith comply with such provisions or this permit shall be deemed revoked. Q v. z CONSTRUCTIONis.riaLENDINGAGENCY Ihereby affirm that[hero iss ed(Sev. 30 len ding agwcy for the performanoeof the woik for which this permit is issued (Sec. 309], Civ, CJ O ULender's Name - - IenderaAddreas a I certify Ihat I have read this application anti stem au d heov abe infsmatom is y correct. l agree m comply with all city and county ordinances and stale laws relating to QTY U' building construction, and hereby suthonze represenmtives of this city to enter uponthe abeve-mentioned property for inspection purposes. (We) agree to .save, indemnify and kap hornless the City of Cupertino against liabilities,judgments, costs and expenses which may in any way scene against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS, Signature bf Applicant/Conractar Date n HAZARDOUS MATERIALS DISCLOSURE ' Will the applicant or future building occupant store orhandle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Cale, Section 25532(a)9 ❑Yes No Will Ne applicant m fantod building occupant use equipment ar devices which ;mit hazardous air contaminants as defined by the Bay Area Air Quality Management District? _ / a ❑Yes rffi"'Iv 1 have read the haxaMous materials requlmmems under Chapter 6.95 of the Cali - forms Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the r Wilding does not current] have maul, that it is tiny reapiaaibilily to notify the occupant f bid rot m m issuance of s Cenifc °t�fK:: "bi , pd_ dho40j 9 - 1s1-. FLA;poR I E rwry .S 4�L tFSS:_ Loss c^ stm ' - rA-S � G .w,., (O G0' Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO sO ELECTRIC PERMIT FEE•• �yGd PERMIT ISSUANCE APPLIANCES -RESIDENTIAL W 20i-1000 AMPS OVERIOWAMP$ SIGNS Et" CAL SPECIAL C ' 41C` TEMP. MF. '.R OR $ ,4 la COMMPR ,IAL. ❑❑ NEW BLDG/ADDITION DEMOLITION >tENPOWER ANT ❑ FOOD SERVICE , ROV D OTHER E % .s 1 D5F SWIMMING POO - SWITCHES- I7 y �� NF.WRESIDENTIALELECTR SQFT. 1 .,SQ] FIC FLOOR ARE i t�jbcb gISQ FTS X35. T T PLUMBINGPERMIT FEE PERMIT ISSUANCE . ALTER- DRAIN &VENT- WATER(EA) MVALUATIOON mow. BACK FLOW PROTECT. DEVICE & DRAINS- FLOOR, R&F. AREA, CORD, STORIES ' OCC GROU TYPECONSTRUCfION APN FIXTURES - PER TRAP O GAS -EA. SYSTEM -1 INC. 4 OUTLETS GAS -EA. SYSTEM -OVER 4(EA)- GREA$EIINDUSTRL WASTE INTERCEPTOR' DING DIVISION FEES - GREASE TRAP PLkWFt I V1 �+ Ekkyy SEWER -SANITARY -STORM EA. 200 FT. WATER HEATER WNENT/ELECTR GRADING E,. WATER SYSTEM/TREATING SOILS WATER SERVICE PAID DatetRecelplR BUILDING FE6 O NEW RESIDENTIAL PLMB. SQ. FC - - 1,. T MECHANICAL PERMIT FEE SEISMIC FEE r� PERMIT ISSUANCE' ELECTRIC HE ALTERORADDTOMECH. PLUMBING FEE AIR HANDLING UNIT GG 10,000 CEM) - MECHANICAL FEE AIR HANDLING UNIT (OVER IQWO CPM)' CONSTRUGTION TAX t - 1s1-. FLA;poR I E rwry .S 4�L tFSS:_ Loss c^ stm ' - rA-S � G .w,., (O G0' Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG Elilmlff -PLUMB MEC ELECTRIC PERMIT FEE•• JOB DESCRIPTION RESIDENTIAL: ❑SFDWL El KITCHEN REMODEL [I ADDITION [I PLUMBING RE -PIPE El MULTI -UNIT ❑STRUCTURAL MODIFICATION , ❑ INTERIOR 1 - ❑ CHIMNEY REPAIR IMPROVEMENT - D BATH REMODEUREPAIR El DEMOLITION DOTTER PERMIT ISSUANCE APPLIANCES -RESIDENTIAL PANELS UP T0200 AMPS 2 �-� 20i-1000 AMPS OVERIOWAMP$ SIGNS Et" CAL SPECIAL C ' 41C` TEMP. MF. '.R OR $ ,4 COMMPR ,IAL. ❑❑ NEW BLDG/ADDITION DEMOLITION >tENPOWER ANT ❑ FOOD SERVICE , ROV D OTHER E % .s 1 D5F SWIMMING POO - SWITCHES- I7 y �� NF.WRESIDENTIALELECTR SQFT. 1 .,SQ] FIC FLOOR ARE i t�jbcb gISQ FTS X35. T T PLUMBINGPERMIT FEE PERMIT ISSUANCE . ALTER- DRAIN &VENT- WATER(EA) MVALUATIOON mow. BACK FLOW PROTECT. DEVICE & DRAINS- FLOOR, R&F. AREA, CORD, STORIES ' OCC GROU TYPECONSTRUCfION APN FIXTURES - PER TRAP O GAS -EA. SYSTEM -1 INC. 4 OUTLETS GAS -EA. SYSTEM -OVER 4(EA)- GREA$EIINDUSTRL WASTE INTERCEPTOR' DING DIVISION FEES - GREASE TRAP PLkWFt I V1 �+ Ekkyy SEWER -SANITARY -STORM EA. 200 FT. WATER HEATER WNENT/ELECTR GRADING E,. WATER SYSTEM/TREATING SOILS WATER SERVICE PAID DatetRecelplR BUILDING FE6 O NEW RESIDENTIAL PLMB. SQ. FC - - 1,. T MECHANICAL PERMIT FEE SEISMIC FEE r� PERMIT ISSUANCE' ELECTRIC HE ALTERORADDTOMECH. PLUMBING FEE AIR HANDLING UNIT GG 10,000 CEM) - MECHANICAL FEE AIR HANDLING UNIT (OVER IQWO CPM)' CONSTRUGTION TAX t HEATING UNIT (TO 10[0,000 BTU) HEATING UNIT (OVER 100,000 BTU) BOILER -COMP (3HP OR 100,000 BTU) OTAL: BOILER -COMP (OVER 100,000 BTU) AIR CONDITIONER ISSUANCE DATE NEW RESIDENTIAL MECH. SQ. Pf. /'1 OFFICE C/