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25849 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ' CITY OF CUPERTINO RmL ;N v -ELECTRIC PERM]fNO. APPLICATION/PERMIT PLUMRN::- MECHANICAL 258 4 .� BUILDING DIVISION BUILDING PROJECT' IDENTIF'ICAT'ION Q P��T�tcltcli�v - q% 07TO LICENSED CONTRACTOR'S DECLARATION Metz I hnebyaffitrn that l am licensed underpmvlslonsofaapter9(commencing with POO Section 700pof Division 3 ultra Businevsund Professions Code.and my license is in tetU� fullfarce and effect. F z W License Lic. a m,z Dam �ConT`S ZO,— A C)IITF.CTS UECL ATI S O_ Z— M I understand my plans shall be used as public records. ~-I-'2 Licenser' Profccsional Q W ce of OWNER -BUILDER DECLARATION KO W U 1 hereby affirm that 1 am exempt from the Contractor's License Law for she W 3 LL y following reason. (Section 7031.5, Business and Professions Cade: Any city or county which regai¢m a perm m construct, alter, improve, demolish, or repair any sweture W� prior to its issuance, also requires the applicant for such permit to file a signed statement O that he is licensed pursuant to the provisions of the Contractor's License law (Chapter dXOLL9(commencing with Section 7")of Division 3 of the Business and Professions Code) EJ or that he is exempt therefrom and the basin for the alleged exemption. Any violation of F.ZQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �= M not more than Jove hundred dollars (S5WL paF-c, [1 h as ownerofthe property, or my employees with wages as their sole compensation, x322 will do the work, and the stmcture is not intended or offered for safe (Sec.]004, Business and Prufasions Code: The Conwaor's Liceme Law does not apply to an owner of propertywhobuildsor improvesthemon, and whodo essuch workhlmselforthoough his own employees, provided tbar such improvements arc not intended or offered forade. IL however, rise 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 purpose of rule.). ❑ Las owner ofthe property, can exclusively contracting with licensed emaciation far construct the pmjm (Sec. 70,PL Business and Professions Code:) The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractors) licensed pursuant to toe Contractors License Law. ❑ I am exempt under SCE. , B & P C for this reason Owner Dam WORKMAN COMPENSATION DECLARATION I hereby affirm that I have a certificate of comenno self -insure, ora certifictte of miters' Counixensinion Insurance., a certifiedcop,diano f(Stt. 3800. Lab C.) which a icy Company / Certified copy is Filedherebyw famished.d, Cenilied copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Has section need not be completed ifthe permit is for one hundred dollars ($IN) or less.) 1 certify that in the peruke tee of the work far which tris permit is issued, I shall am employ arty person in any manner so as to Exempt subject to the Workers' Compensation Lawsof Califomia. Date Applicant z O NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should lq become subject to the Worker's Compensation provisions of the Labor Core, you must a 7 forthwith comply with such Provisions or this permit shall he deemed revoked. 1 O CONSTRUCTION LENDING AGENCY z I hereby affnn that there is a construction lending agency for the performance of V O the work for which thu pemoit is issued (See. 3090, Civ. C.) Lender', Name 0 Lenders Address 1 ccrsify that 1 have read this application and state that the above information is Correct. l agree to comply with all city and county ordinances and mute laws relating to In building construction, and hereby authorize representatives of this city to enter clam U z above -m - dproper, for' di p res. 1 c) age a to save,' a ify a cop harmkaI than ,y of Criticism against liabili es,jud ems,c n xpe which may in ay.ecruce st said Ciry Inco yue eofth ung Matson / HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle haeardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Sian 25532(.)1 ❑Yes XNo Will the applicant or future buildingoccupant u.ssequipmenmrdeviceswhich emit wardoua air commercials as defined by the Bay Area Air Quality Management IJistrictl ❑ Yee yl No I have mad the hasallous ¢rials requmm"'n der C apmr 6.95 of the Culealth&SafetYnen ac ius 25505,2 and2553.IundersmnJ that il't build gdes'not l tenarn.I it is my res sibility to notify the a pant the reyu' m l et pine, of . Craftiness, of ilz/ mooed cT eL~11 iA.0 ELECTRIC PERMIT FEE PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 20o AMPS 201 - 1000 AMPS OVER INN AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. Let c) l - TEMP. METER OR POLE MST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES r NEW RESIDENTIALELECTR _SQ. FE IQTY.I PLUMBINGPERMIT I FEE I ALTER - DRAIN & 1lklft- WATER (EA) DRAINS - FLOOR,R OF, R, C ID. FIXTURES - PER TRA 1 GAS - EA. SYSTEM -I INCA T S GAS - EA, SYSTEM -OVER O(, ) t \� GREASFJINDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER - SANITARY - STORM EA. 200FI'. WATER HEATER W/VENT/ELECTR WATER SYSTEMRREATING NEW RESIDENTIAL PLMIL SQ. FT. I-.- ❑ I � rtOl BUILDING PERMIT INFO !OB 52®�Cp ZQ�2.I�i t. 0WZEA MECHANICAL PERMIT FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT ('1'0 10,000 CFM) AIR HANDLING UNIT (OVER 10," CFM) EXHAUST HOOD(W/DUC-n I �� HEATING UNIT (TO 1 W,IKKI BTU) HEATING UNIT (OVER 100,0110 BTU) VENTILATION FAN (SINGLE RESID) BOILER-COMPLIHPORIW,000BTU) l BOILER - COMP (OVER IN." BTU) NEW RESIDENTIAL MECH.—SQ. FU PAID Date BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECIIANICAL HE CONSTRUC IONTAX # PAID Data Recta, ELI, ISSUANCE DATE o1 �aP 15 A o D��i/1 tltlb V ISSUED BY: FEE SUMMARY OUTSIDP FEES SANITARY Y _N RECEIPT # SCHOOLTAX Y 014 RECEIPT' # 1 PARK FEE YN �I) 'CI:IPT p V I IN IVISION FEES PLANCHEC sF, GRADI FE SOIL FEE ENERGY FEE MECHANICAL PERMIT FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT ('1'0 10,000 CFM) AIR HANDLING UNIT (OVER 10," CFM) EXHAUST HOOD(W/DUC-n I �� HEATING UNIT (TO 1 W,IKKI BTU) HEATING UNIT (OVER 100,0110 BTU) VENTILATION FAN (SINGLE RESID) BOILER-COMPLIHPORIW,000BTU) l BOILER - COMP (OVER IN." BTU) NEW RESIDENTIAL MECH.—SQ. FU PAID Date BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECIIANICAL HE CONSTRUC IONTAX # PAID Data Recta, ELI, ISSUANCE DATE o1 �aP 15 A o D��i/1 tltlb V ISSUED BY: