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27369 (2)- USE BALL POINT PEN ONLY (CITY OF CUPERTINO APPLICATION/PERMIT PLUMBMG MF,CHANICAI. rn 273691 BUILDING DIVISION III NG ING PRO.IECT I[)ENT INICATION LICENSED LICENSED CONTRACTOR'S DECLARATION Matz Iherc itfifirm that l am licensed under provlsiomofCluipter9(commencing with woo Section ]000) of Division J of the Business and Pmfosions Code, and my license is in y� full forte and effect. FZ� License Class Lic.11 mQy Date Convector Z FOyZ ARCHITECTS DECLARATION OZ— O I undersand my plans shall he, used as public records. QNFJ ,1 geJ Licenced Professional yeegeQ OWNER -BUILDER DECLARATION KC W, I hereby affirm that I am exempt from the Contmctar's License law for the W following reason, (Section 9031.5. Business and Professions Code Any city or county F �-�; which reqirewm an us a Permit construct, alter, improve, demolish, or repair y structure��}� prior to its issuance. also le9oirts Ne applicant for such permiuo file a signedsammut K ¢O that he is licensed pursuant o the Provisions of the Commemr s License law (Chapter X.a a.X 9(commencing with Section ]000)ofDivision 3 offle Business and Pmfessiom Code) or that he is exemptherefrom and me basis for the alleged exemption. An 14 f ,_Zjg pian, yvioa ono FZQ Section aw. than by mydreddantfor apewis subjects the apPlicmuoecivil paternity of SCO nm more owu five hundred dollars(Sem). as atm ❑ do fou thenrufflae somny,ormycmtended witheres ant forsheirsoole .7044, runion, 2i— will dothewons ander he Comiinor'sLicese Laoffereddoes not to wo Business and Professions Code: pr Contractor's 11he mr's License Law Jaen not apply tort owner of ownenywhob. buildsorimproves thereon, and whodaes such work himselfedthrough his employees,pmvidWmpr such impmvemwthin not ewofcJoroecrtd Thede.IL however,thebuilding or den of improvement is hath within one year or completion, t purpose r- ble.). will have the burden of proving that be did not build or improve for putposwf ale.). ❑ Iuel owners(mc PropSec. 70,14. Business and Prraming unis Cith licen'M contractors to conLicense et the project (Sec. in ncrol s and ywhol mid Gxmprove Contractor's Licenm Luwdocs such apply to on owncovaracrperty wFo sed puns ant to theoeContractor's License raw. for such pmjeeu with aeonuucmr(s)Ikensed DursuuntmIM1e Cnnaaemr'e Ekes¢ Lew. ❑ 1 em exempt under gee. . 11 & 1' C fur this rcaaon Owner Date WORKMAN COM P17NSATION DECLARA'I UM ❑ Iherehy affirm mm lhavcucertilicalc of ttmsnt er self -insure, orncertiRcutc of Workers' Employee a n Ire this p ora cenlOeJ copy merrof (Sec. JX(Nk Lub C.1 whjeM, rs all employee under this pewit. _ PolicyN Company ❑ Cenifedcupyishcrebyfumished. ❑ Certified copy is fled with me city inspection division CERTIFICATE OF EXEMPI'I OM WORKERS' COMPFNSATIO NSURANCE (Thkov,donnceJnotbecompletedi the,mantxfmonehumbeddollan (SI 1 or tossed lemifyflisamtheperformanceofth workforwhich mix permit ix is d I. 1 not employ, any person in any manner s as to hccnme sub' t to ers' z Compewtionlawsof Califomia. Date e Applicant z NOTICE'TO APPLICANT:If.ahermaking lhi Ti0cute of Ea n,ywshould. F(/] becomesubjs"B'the Workers Compensation Dm isinns x(111 bar "mamLLst ? foMwith comply wird such provisions or This Ix shall be deemM v kW. d Q C(NSTRUCf10N LENDING ENCY Z I hereby affirm That shcm is a conswctinn lending ency for she performance of U C) the work for which this pewit is issued ISa. 309), Civ. ) I endo, Name 0I" Lenders Address V 1 certify that l have read his applintion and sum roar a above infortnedon i } correct. IagrecwcmdPlywilhallcilyvr `Ci.mIy ordinances sate laws relaxin E" ran' building conswedun, and hereby uumoriu rtpresenusivesof mi, ilymenmru she U Z above-memimod Property for inspersion DuOnses. (We) agree to save, indemnify and keep hawlcss rhe City o ape no against liabilires.judgments, coxa and expenses which may in any way novice against said City Sigatm of ApplicaogC9dmacmr Vane 11 HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building nixupont store of handle hazmdom material aet defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety Code. Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupvm use equipment or devices which emit hazardous air commitments as defined by the Boy Area Air Quality Mmogemem District? ❑ Yes ❑ No 1 have read rhe Inaurdoux materials re,mmuams under Chapter 495 of me Cal romiu I Icahh & Safety Cale, Sections 25,105, 25533 and 25534. 1 undersand that if the building does not currcnJy basteamnanl, ibm it ix my ¢eponniWay I notifythe a:cupnm of the scinuo,ovents which most he nmi prior to issuance of u Certificate of acapanry. Owner or omhmizcJ agent Date ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENUAL PANELS UP TO 200 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIALCMCUIT/MISC. TEMP. METER OR POLE MST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES SQ. FT. PLUMBING PERMIT PERMIT ISSUANCE AurrR - DRAIN & VENT- WATER (EA) RACK FLOW PROTECT. DEVICE DRAINS - FLOOR, ROOF, AREA, COND. FIXTURES- PER'rRAP GAS - EA. SYSTEM -1 INC 4 OUTLETS GAS- A. SYSTEM-OVER4(EA) GREASFJ DUSTRL WASTE INTERCEPTOR - STORM EA. 200FT SQ, PT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO Ur" CFM) AIR HANDLING UNIT (OVER 10.011) CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER Im,mO BTU) VENTILATION PAN (SINGLE RESID) BOILER -COMP LIHP OR 100.000 BTU) BOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ. FT. FEE FEE IN] ❑ J ❑ 10 Fyn SCBIPf10N SQ. FT. FLOOR AREA SNQ. FT. PETE SUMMARY SANITARY Y N RIiCRIPI' b SCI{001. TAX YN PLANCHECK EEE GRADING FEE SOILS FEE ENERGY FEE PAID Dae HecciptM BUILDING FEE SEISMIC FEE ELECTRIC FEE FEE PLUMBING FEF, MECHANICAL. FEE CONSTRUCTION TAX PAID Dutc Rcccipi p 1 renal FEB 81995 CI I Y Vr, L, urcri I five 59 ISSUED BY: