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99110153ICf a3 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY jO BUILDINf. - ELFC'1'RIG\I, PERh11T NO CITY OF CUPF.RTINO PLUMBING-MECnnNlau. BUILDING DIVISION APPLICATIONIPERMIT CONTACT: �antrl �gTVLoL liter W(d. ii4 Poe R17AJO r—A, 9Sd1`1 PHOSO41 RACORN NAME: TJow � LIC NO: —(030 4—" PATROL 422/ 3 /o NEC LIC NO�� AAUUURESS: O 3 1 Irl 01 ISW S2z-SVb1bI ❑ Consultarl Paid by Applicant (initial) LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT I hereby affirm that I am licensed rude, provisions of Chapter 9 (commencing with Section 90007 of Division 3uf the Nosiness and Profcesiors Code andery licensees PERMIT ISSUANCE ntaliforeeawetfecy. 3� i 13to licensee Class V x AI'I'LIANCES-RESIDENTIAL pate \\ 23-� Contractor ARCHITECT'S DEC PANELS I understand my plans shall be used as pubh it, UP TO 100 AMPS OWNER BUILDER DECLARATION I hereby affirm flit 1 am exempt from the Contractor's License law for the following reason (genion 9031.5, Business and Professions Code: Any city or county which requires o pened to conslmm, ahm. rupture, demm"It. or repair any strucmle priorlo lex issuance, alsorugmtec the applicant fursuch permit to Na a. signed statement that he Is licensed pursuant to the prnvlslons of the Contrac er's License Law (Chapter 9 (nunmencing with Section 91X10) of Division 3 ofthe Business and Professions Crile) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for it Perot subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I. as meaerofmc properly or my employees with wages as their sole compensation. will do the work. and the stmctom is not intended or offered for sale (Sec. 701 Business and Professions Cade: The Crmmclnrs License Use does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employee,, provided than such improvmnena ere not intended or offered for sale. If, however, the building an infpmvenmm is sold within one year of completion, the —builder will have me burden of pr. ing that he did not bill,] or eepro a for pury pose of'n:da.). ry v ❑ I, as owner of the properly, am exclusively connecting with licensed contractors to msaun the project (Sec. TW4, Business and Professions Code I The Contractor's Li- cense Law docs not apply to an owner of property who builds,, improves thereon, and who common for such projects with a communist licensed pursuant o the Contractors License law. ❑ 1 am exempt under Sec. . B & P C for this reason Data WOR KERS COMPENSATION DECLARATION 1 he,el+y affirm under pcunity ol'perjury one of the Unloving dedimalmar. I have nd will maintain a Certlfiam A Consent to self -insure I'or Workers Gmlpcn- us provided for by Section 370(1 of the Labor Code, ha the Ia forti ne, of the dfor which this Permit is Issued. I have and will maintain Workers Compenvtion Insurance, as required by Section To of the Labor C.moo^ �e eantvnec�f7 a work for which this permit is issued, ilrmer and POhcv number art: OVER 1000AMPS SIGNS ELECTRICAL SPECIAL CIRCUE UMISC. TEMR METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR SQ IT. _ Z2— I UTI'. PLUMBING PERMIT I FEE I COMPENSATION INSURANCE, This—arm need nil be contplcted if the permit in for one hundred dollars FS 10d) lass.) I certify that in the performunecnf the work for which this Iter d l shall nth Ls issued, urn employ any perm in any invnner sex ns m become suhjcet tome WorkersC.ontpeo- Z svaoa Lrws of California. Date Z O Apprcarr 1 - NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should a ? become subject to The Workers Compensation provisions of the Labor Cade. you must forthwith comply with such provisions or permit shall he deemed rooked. CONSTRUCTION LENDING AGENCY V C)Thereby affirm Nauhere iso rnrtmelion lending agency for Performance of Fme wank fur which this Pemlhis iasud(Sec.3o99.Civ.CL U Lender's Name - U.1 Lender, Addreas 1 certify that 1 have read alis :mplimaiol and state Nat the ahave information is correct 1 agree to comply with all city and county ordinances and state laws relating to QTY O Z building cotlswaion. and hereby atnhorlm repress ratios s of Nis city to enter upon the aMwe-mentioned property for inepeaian purposes. Ove) agree to save, indemnify and keep hamdev, the City of Cupertino against liabilitieu,judgmems, costs and espouses which may it any way acerae ageiret said City in consequence of the granting sef this permit. APPLICANT UNDERSTANDS AND WILL CONIJY WITH ALL N(JN-POINT HAZARDOUS MATERIA DISCLOSURE M1e applicant or fumm builAing occ atsmroorhandlc humnlous nmaterial 1s defined by the Cupertino Municipal Cde, apmr 9.12, and the Health and Safely 'dc. Section 25532nd! EJ Yes ❑No Will The applicant or future building occupant use equipment or devices which :mit huadous air commitments nts as defined by the Huy Arta Air Quality Monagemem District? E] yes ❑No I have readtl I 'Wril' liquirclormsord Chapon, 695 o1 me Coli f mm 11 .Ice & Safep Code Sections 25505 25533 uyd 25534, I d... and Thal I me I._. .,.,,.... .,Ji{n. i/iria Eft t .dynhe«euparl PERMIT ISSUANCE ALTHR - DRAIN & VENT- WATER (IIA) HACK PLOW PROTECT DEVICE DRAINS - FLOOR, ROOF, AREA, CONI. FIST URES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OU'I LEIS GAS - ISA. SYSTEM -OVER 4 (EA) GRIIASEANDUSTRL WASTE INTERCEPTOR GRFASETRAP SEWER -SANITARY - STORM EA. 211111'1'. WAIFR III'ATER W/VENT/F.LECI'R WATERSYSTEM)TREATING WAI ER SERVICE NI2W RESIDENTIAL PLMU SQ, IT. TOTAL: MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT fro 10.0011 CFMI AIR HANDLING UNIT (OVER 10.001 CPM) EXT IAUST I IOOD (W/DUMI HP.A'rINC, UNIT (TO 100,00K) BI U) LEAFING UNIT (OVER 100.000 BTU) VENTILATION FAN (SINGLE RESIII) BOILER - COMP (3HP OR 1110.000 BTU) BOILER- COME (OVER 100.000 I3'1'U) ' AIR CONDITIONER NEW RISSIDENTIAL MECH. SQ. FII TOTAL: OFFICE FEE SQ. FL FLOOR ARBAI S/SQ. FP CONSTRUCTION I BUILDING DIVISION FEES 1'I.ANCHHCK FEE FNISRGY FEE GRAINING FEE BUILDING FHP. ELECTRIC FEE PEUMBING FEE MECHANICAL FEE CONSTRUCTION 1'AX HOUSING MITIGATION FIZE. I'All) Date Rcccipt Xf ISSUANCE DA ./ ISSUED BY: BUILDING PERMIT' INFO BLDG ELECT 1'LUbNi MECH E] El❑ FEF, JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑KI'ICHENREMODEL ❑AUDITION [_1 PLUMBING RE+'11'1: ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑INTERIOR ❑ CHIh1NEY REPAIR IMPROVEMENT ❑SWIMMING POOLS ❑ BATH REMODEDREPAIR ❑ DFMOLEI'[ON ❑ OTHER COMMERCIAL: ❑NEWBLDG/ADDITION []DEMOLITION []TENANT ❑ FOOD SERVICE IMPROVEMENT ❑THER I UTI'. PLUMBING PERMIT I FEE I COMPENSATION INSURANCE, This—arm need nil be contplcted if the permit in for one hundred dollars FS 10d) lass.) I certify that in the performunecnf the work for which this Iter d l shall nth Ls issued, urn employ any perm in any invnner sex ns m become suhjcet tome WorkersC.ontpeo- Z svaoa Lrws of California. Date Z O Apprcarr 1 - NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should a ? become subject to The Workers Compensation provisions of the Labor Cade. you must forthwith comply with such provisions or permit shall he deemed rooked. CONSTRUCTION LENDING AGENCY V C)Thereby affirm Nauhere iso rnrtmelion lending agency for Performance of Fme wank fur which this Pemlhis iasud(Sec.3o99.Civ.CL U Lender's Name - U.1 Lender, Addreas 1 certify that 1 have read alis :mplimaiol and state Nat the ahave information is correct 1 agree to comply with all city and county ordinances and state laws relating to QTY O Z building cotlswaion. and hereby atnhorlm repress ratios s of Nis city to enter upon the aMwe-mentioned property for inepeaian purposes. Ove) agree to save, indemnify and keep hamdev, the City of Cupertino against liabilitieu,judgmems, costs and espouses which may it any way acerae ageiret said City in consequence of the granting sef this permit. APPLICANT UNDERSTANDS AND WILL CONIJY WITH ALL N(JN-POINT HAZARDOUS MATERIA DISCLOSURE M1e applicant or fumm builAing occ atsmroorhandlc humnlous nmaterial 1s defined by the Cupertino Municipal Cde, apmr 9.12, and the Health and Safely 'dc. Section 25532nd! EJ Yes ❑No Will The applicant or future building occupant use equipment or devices which :mit huadous air commitments nts as defined by the Huy Arta Air Quality Monagemem District? E] yes ❑No I have readtl I 'Wril' liquirclormsord Chapon, 695 o1 me Coli f mm 11 .Ice & Safep Code Sections 25505 25533 uyd 25534, I d... and Thal I me I._. .,.,,.... .,Ji{n. i/iria Eft t .dynhe«euparl PERMIT ISSUANCE ALTHR - DRAIN & VENT- WATER (IIA) HACK PLOW PROTECT DEVICE DRAINS - FLOOR, ROOF, AREA, CONI. FIST URES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OU'I LEIS GAS - ISA. SYSTEM -OVER 4 (EA) GRIIASEANDUSTRL WASTE INTERCEPTOR GRFASETRAP SEWER -SANITARY - STORM EA. 211111'1'. WAIFR III'ATER W/VENT/F.LECI'R WATERSYSTEM)TREATING WAI ER SERVICE NI2W RESIDENTIAL PLMU SQ, IT. TOTAL: MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT fro 10.0011 CFMI AIR HANDLING UNIT (OVER 10.001 CPM) EXT IAUST I IOOD (W/DUMI HP.A'rINC, UNIT (TO 100,00K) BI U) LEAFING UNIT (OVER 100.000 BTU) VENTILATION FAN (SINGLE RESIII) BOILER - COMP (3HP OR 1110.000 BTU) BOILER- COME (OVER 100.000 I3'1'U) ' AIR CONDITIONER NEW RISSIDENTIAL MECH. SQ. FII TOTAL: OFFICE FEE SQ. FL FLOOR ARBAI S/SQ. FP CONSTRUCTION I BUILDING DIVISION FEES 1'I.ANCHHCK FEE FNISRGY FEE GRAINING FEE BUILDING FHP. ELECTRIC FEE PEUMBING FEE MECHANICAL FEE CONSTRUCTION 1'AX HOUSING MITIGATION FIZE. I'All) Date Rcccipt Xf ISSUANCE DA ./ ISSUED BY: