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S 09561- K 1 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - EUE(Tk CITY DIVISION APPLICNFION/PERMIT r r vl-�Muorv(,a`n lootN o. 3&- N W©Lf�z---: KU rNN ,-.A., X%i5_//Jll1 I Ct PHONE: V L d`( ,r ^_ ❑ Consultant Fees Paid by Applicant (initial) CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT I hereby affirm dun Ian licensed ruder pmvisina. Of Chapter 9 (comnandng yagZ with Seed on 70(Xfol1)ly Inion 3dUdd Business and P m ' Code. and my license O in toll frau and cf4•/�rY��r �a Y ZLLz U [)air— )air Class —b Conti L n6y Unm CTS DECLARATION a ARCHI'I'F.Cf:S DECLARATION zyZ Imadecaund my pl:mnshall be used as public record., F Licensed Pnde%si ded OWNER -BUILDER DECLARATION C OW Q 1 hereby affimt that 1 am exempt from the Contractor's License Law lar the a U following rtasea (Section 7031.5, Business uad Pmfessinns Code A, city or..umy 3 LL y which requim, a permit nth sen orc1, alcor, improve, demolish, or repair uny stmaure LLOQ prim'.it, issuance. also requires the applicant for such Permit 0 file a signed lemement the he is licensed p or, uanuo the provisions lulhe Contractors License Law (Chapter 9 X00 (commencing with Sermon 701 of Division 3 mthe Bu%ml and Professions Ede) or Xe M that he is exempt therefrom and the basis for the alleged exemption. Any violation of W m Section 7031.5 by any applicant for a pximit mhj do, the applicant to a civil penalty of not more than five hundred dollam ($5000 O C Las owner of the pmpcdy, or illy employees with wages as their sole compensation, L. wiIIduth vmd,mvI lEeabueure isnot intended mutteyed fOrsvle(Sec.AWl. Bu sine ss L'3 m and Pmfeasinns Calc: The COnlmmor's Lwmlw Law dues not apply to va owner of pO,,Oy who builds Or improve, Thereon, and who dues such work himself or through his own employees, provided that such improvements am not intended or offered for sale Ill however, The building ser intpmvcmem is sold within one year afconlpletion, the er.hul fuer will have the burden or proving that he did not build ser iTaprove Iia per pct c ^('sale). [:]I l tire property.ly contractingwthI mcialed tact _m construct tP J t (Sec. 7WL Business andprofessors Code:) ThContractors U. c L J t apply I I p p nY n build . p al m d QTY. who contracts for such pr hju's with it c I t l) licensedpursuant tthe Cls r'a License Law. C I an exempt under Sec. . B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I heathy affirm under penalty of Perjury One Of the following declarations: I] ( have and will mai maim tion 37W of the Labor sells.for t for Performance Cemf the tylion, as provided for by Section 3]00 of the Lahr Code. for the performance of the work for which this permit is issued. 0 1 have and will maintain Workers Compensation Insurance, as tryuired by Sectio. 3700of the IrMe Code, Latin. performance of the work for which this permit is issued. PERMI IISSUANCE API-IJANCES- RESIDEN'TIAI. PANELS UP TO 201 AMPS SIGNS ELECTRICAL SPECIAL CIRCUITMISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELE R OUTLETS - S W ITCHES - FIXTURES NEW R ESIDP HAL ELECT R SQ II'. COMPENSATION INSURANCE (This section need not be completed ifthepcmtiLLs for one hundred dollars IS I IMq or less) 1certify (hut eInc any iemaaceof the work for which this thePermitWok issued. )shall nor aTnpnY tiny peomt in any manner sn m m M1eahmc xuhlect lathe Workeri Q1111pc11' Z emir. Lowe Of California. Mile z Q Applicant 1 NOTICH TO APPLICANT: If, after ne um, this Cvmficam of Exemption, you should M1cehme s,h ial nth The Wnrliters Componsvden provisions Of the labor Coda you nest forhwhh comply with such pmvi%inns or this permit shall he deemed revoked. a n' MSTRUCTIONLENDING AGENCY U O that (hereby affirm thm'hem isaconmmctinn lending agency lm the performance of Li. the work far ,sell his pe,.at, is issued (Sec. 3017, Civ. C.) C) 6.1 lender's Name %" U Lenders Address 1 cenify that 1 have read this application and %tate that the above inhmnatien is Fto comert. I agree to comply with all city and county ordinances and state laws tenting to QTY. U z building construction, and hereby valmaim mpresenlatives of this cilym enter upon the move -mentioned pmpcny for inspection purposes. (We) agree m save, indemnify and keep heatless the City Of Cupertino against liabilities. jud, gnm l .,is and expenses which may in any say ream again%1 'd' City in consequence of the granting of this permit. soul FCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT HAZARDOUS MATERIALS DISCLOSURE will Lha npplicum Or name M1nilAing aceupnnt %lureahandle hae...I nmcriw as defined by Thu Cupertino Municipal Code, Chapter 9. 12, and the [Icahn mW Safely Code. Serio V532m)'! E3 Yes El NO Will he applicant Or future building Occupant use equipment or devices which emit hmuNom air contaminants as defined by the Bay Area Air Quality Management District! ❑Yes -1 No 1 have read the Immature, materials reydmmeno under Chapter 6.95 of the Call - India Health & Safety Code, Sections 25505. 25533 and 25534. I understand that if the building docs not cuecn0y have a Tenant, that it is my responsibility to notify the occupant .film mryiremems which mus' be met diess. issuance of a Certificate of Occupancy. Owner or mamind agent Date PLUMBING PERMIT PERMIT ISSUANCE ALTER -DRAIN & VENT - WATER (EA) BACK FLOW PROTECT DEVICE DRAINS - FLOOR. ROOF, AREA. COND. FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OUTLETS GAS- EA. SYSTEM OVER a (IEA) GR17ASUINDUSTRL WASTE INTERCEPTOR GRHASETRAP SEWER -SANITARY -STORM EA, 200 PF. WNIER HEATER W/VENTPULECTR WATER SYS'IEMTREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. IT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10.000 CFM) AIR HANDLING UNIT (OVER (BOX) CFM) EXHAUST HOOD(W/DUCT) IIFA'I'ING DNIT ('rO l (a),BBO HTU) HEATING UNIT (OVER 10,SX) H IU) VENTILATION FAN (SINGLE RESID) BOILER - COMP (311P OR 10(1.00) BTU) BOILER - COMP (OVER 100,00013'HD AIR CONDITIONER NEW RESIDENTIAL MECH. 50.191 OFFICE FLEE JOB DESCRIPTION 75" is" 0 9 5 6 NITARY NO. APPLICATION S WAROTA(. C KI'I C1117N REMODEL ❑ AUDI T]ON ll NIC CS'1'RUCI URAL CON 'rROL.x MODIFICATION C INTERIOR C CHIMNEY REPAIR IMPROVEMENT El SWIMMING POOLS C HATH REMODEL REPAIR C DEMOLITION C OTHER BUILDING PERMIT INFO BLDG ELECT PLUMB MUCH ❑ il?� ❑ ❑ JOB DESCRIPTION RESIDENTIAL C SFDWL C KI'I C1117N REMODEL ❑ AUDI T]ON [:1 PLUMBING RI PIPF ❑MULTI-UNTI' CS'1'RUCI URAL MODIFICATION C INTERIOR C CHIMNEY REPAIR IMPROVEMENT El SWIMMING POOLS C HATH REMODEL REPAIR C DEMOLITION C OTHER COMMERCIAL C NEW BLDG/ADDITION ❑DEMOLI'HON ❑TENANT ❑FOOD SERVICE IMPROVEMENT ❑OTHER SQ. FT FLOOR AREA $/SQ. 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