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S2929Q1:4 Z 0c) W U Z r�ildpW, _14- J a ,OwU I`3U,F" �Oa aqo W ^M'tn �za x W�° a3� APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: �� �� �/ OWNER'S NAME: PHO CONTRA R'S A E: LIC NO:, �r�t �--i r� - �'� ARCHITECT/ENGINEER: ADDRESS: CONTACT: PHONE: i ICENSED CONTRACTOR'S DECLARATION Q.LY. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 qf the Business and Professions Code, and in ice nse is in full force an Y 17 License Class c. # o'- Date Contractor. A CHITECT'S DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or 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 pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and QTY, who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self- insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My WoM C p sa eer and Policy n / Carrier Policy No.: CERTIFICATE OF EX MPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compen- Z sation Laws of California. Date Z0 Applicant 0_4 V) NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should (~ H become subject to the Worker's Compensation provisions of the Labor Code, you must W > forthwith comply with such provisions or this permit shall be deemed revoked. A %. CONSTRUCTION LENDING AGENCY U O I hereby affirm that there is a construction lending agency for the performance of w 0-4 the work for which this permit is issued (Sec. 3097, Civ. C.) O U Lender's Name 0 U Lender's Address I certify that I have read this application and state that the above information is iFi V] correct. I agree to comply with all city and county ordinances and state laws relating to QTY. U Z building construction, and hereby authorize representatives of this city to enter upon the rr above- mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPL ANT UNDERSTANDS ND L COMPLY WITH AL NO POINT SOU C REGULATIONS. A Big j, Si re of pp lic n ra r Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? tt // El Yes LyN. Will the applicant or futu,,, building occupant use equipment or devices which -� emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? j�'t F1 Yes I have read the hazardous materials qu rements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Se ions 2 05, 25533 and 25534. I understand at if the buildipg�crgs not currently have a enan that' is my responsibility to notify occugl it of th uiran=ts which must b r to issuance of a Certificate ofIQcuiAi Z. authorized agent �/ ' -/ Date ) 0 N/C DAT Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ❑ ❑ ❑ y ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ SWIMMING POOLS ❑ BATH REMODEL/R PAIR ❑ DEMOLITION ❑ OTHER PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS 201-I000AMPS OVER 1000 AMPS SIGNS ELECTRICAL, SPECIAL CIRCUIT /MISC. TEMP. METER OR POLE INST. COMMERCIAL: ❑ NEW BLDG /ADDITION ❑ DEMOLITION ❑ TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS — SWITCHES — FIXTURES NEW RESIDENTIAL ELECTR SQ FT. SQ. FT. FLOOR AREA $ /SQ. FT. TOTAL: 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 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER — SANITARY — STORM EA. 200 FT. WATER HEATER WNENT/ELECTR WATER SYSTEM/TREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER — COMP QHP OR 100,000 BTU) BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER r -4 NEW RESIDENTIAL MECH. SQ. FT. FEE 4 I __STORIFS TYPE CONSTRUCTION OCC.GROUP APN BUILDING DIVISION PEES' PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Date Receipt # TOTAL: BUILDING F FEE SEISMIC IQ MECHA AL FEE CONSTRU ION TAX HOUSING M GATION FEE PAID Date Receipt # ISSUANCE DATE ISSUED BY: