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21564APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Build Ing Add �o t /4P( C. �� PERMIT NO. 21564 ' Ph "' 5 7 CITY OF CUPERTINO- BUILDING DIVISION APPLICATION /PERMIT BNLDINGELECIRICALPLUMBING mrCHAIICAL APPLICATT57MMIPTITAT71= l T IJIJ ontactmsName: Lic. No: - r/(✓ / C CATEGORY CONTROL p Architect /Engineer. ' Lic. No: . -- QIY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addrovar ' PERMITISSUANCE IZ(1'S j� ❑ L-r1. ❑ ❑ —J� LICENSED CONTRACTOR'S DECLARATION Ihth Brensect ofChapter IngwltI I fun7000)ard eff n3o(theBusinmand Pm(cssloneC.de, and my licenm le In full m e and effect +�. Lirensc Cla LI[.N �-Z / �� / Da meracmr ARCHITECTS DECLARATION I understand my plans shag be used as public records. Licensed Professional OWNER - BUILDER DECLARATION 1 hereby efRrce that I am exempt fromthe Contractors License law for the following reasan.(Scction 70315, Buslneseand Professions Code: Any city., countywhich require. a permit to construct, alter, Improve, demolish, morpair anystmcture Imurto its issuance, also requireathe applicant forsuch permit to file a signed statement that he is licensed pursuant to the provisions of the Contl.dur , License law (Chapter 9 (commencing with Section 7o W) of Dlvi- ,m3of the Businmss dProfmlom C.de)orthathelaexemptthel (romand the basis for the alleged exemption. Any violation of Section 7IHS by any applicant for a permit subjects the applicantto a civil penalty of.. more than five hundred delta. (SSW). ❑I, as owner of the property, or my employees with wages as their sole compeneatlon, wBldo the work and thestrurnme Is not intended or offered for sale (Sec. 7W4, Business and Profeadoes Code: The Contractors License Law does not apply toan emmerof property who builds orimproves thereon , and who does wchwork himself or through his own employees, provided that such improvements, are not intended oraffered for sale. IL however thebuilding er impmvement Iswld withinoneyearofcomp:dion,the owner- bu- derwlllhave tl�,Jiurden of proving that he did not build or improve for purpose of uleJ, U I, as owner of the property, am exclusively contracting with licensed coutnci.n to co etnict the project (See. 7644, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who bunts or imprwea thereon, and who contracts for such p(ojecta with a cgBOartor(# licensed pursuant to the Contractor'. License Law. LJ I am exempt under Sec B k P C for this reason MPWANCFSRESIDENTfAL JOB DESCRIPTION - 5 �`n �f PANELS 301,10DOAMPS OVER 1000 AMPS SQ. FT. FLOOR AREA - E /SQ. FT. SIGNSELFLTRICAL 1 SPECULCIItCUIT /MISC 7� GO TEMP. ME-fIX ORI l, INST. POWER D ES SWINMINC C ETSSWI )(TARES VALUATION NE RESIT ELECTft SQ STORIES TYPE CONSTRUCTION QTY. TAL: —ij PLUMBING PERMIT FEE OCC. GROI/P RF5. UNITS pp LL fSSUANCE ALTER -DRAIN kVENT- WATER (FA) b7pOD 7DNE APN BACK PIAW PROTECT. DEVICE FEE SUMMARY DRAINS FLOOR ROOF, AREA, COND. FI)CIURFS PER TRAP SANITARY Y N� RFLEUrr p Owner Date WORK MAN COMPENSATION DECLARATION ❑I hereby affirm that I have • leverate of e convent d spbinwrc, or a 3800,abC.Workeni Compewtlonlwurana oracertl( led copythemof (Sec. Policy lab C3 Polley p SCHOOLTA% Y_ N_ RECEIPT M GAS EA. SYSTEM-1 INGd OUTLET'S . PARK FEE Y N CAS EA,SYSIEM- OVCRd(EA) Coss an y DING IV BUILDING DIVISION ISION FEES Certified copy Is hereby mmle city Certified copybfiled with the city Irepectlon divitlon. CERTIFICATE OF E'1(EMPTION FROM WORKERS' COMPENSATION INSURANCE Qhissectl.n readout be completed tithe permit Is forone hundred dollars ($100) or lm3 1 eartlfy that In the performance of the work for which this perrrdt is Issued, I shall not employ any person In any manner as to come je tot Worken'Compen .n veal tare . at am CREASE /INDUSTRL WASTE INTERCEPTOR PLANCI -IECK FEE PAID Date Rem t# GRFASETRAP SEWER - SANITARY -STORM FA. 2001117. WATER HEATER W /VENT /ELECTR ENERGY FEE Y N- PAID Date ReCet t# WATER SYSTEM /TREATING NEW RE9DENTIAL PLMB. _`.QFT. NOTICnI,— NOTICE OA APPLICANT: If, ale kin sCeri Certificate Examptl ,you should become subject to the Workers' Comperwtlon provisions of the Labor Code, you ,,coat forthwith comply with such provisions orthia permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Ifeerebyaffirce thatthrectsa construction lending agency for the perform ance of the work for which this permit Is Issued (Sec 3097, Civ. C.) Lander'. Name Lender. Address I cedlfy thatl havereadthisappliation and statethatthe above Information bcormd. Iegreetocomplywith allcityand countyordlnanmandstate laws relating to building construction, and hereby authorize representatives of this city to enter upon the above- mentioned property for Inspection purposes. (We) agree to save, Indemnify an d keep harnelm the City of Cupertino against Babuities, judgments, cosh and expenses which may lna way acme against said City in o granting of this permit. 1-41Z 3 TOTAL: BUILDING FEE SEISMIC FEE TOTAL: ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID: - ALTERORADDTOMECH. 'Date Receipt# AIR HANDIJNG UNIT (TO 10,000 CFM) SUBTOTAL: AIR HANDLING LBarr (OVER 1B,m6cFM) . CONSTRUCTION TAX 5 m reof Appli ara or Date H RUOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the 75933(.)7 I ealth and Safety Coder MN. ❑ Yea 1I No Will the applicant or future building occupant use equipment or devices which emit hazardous air cont ncra eas defirud bythe Bay Area Air Quality Management District? 4 Yea No have read the hav .dy C.d,Scdi.ulremenlsund and 25534. of the understand that if (he k Code, Seetumentl have a73 and tenant, that 1 rspnland that ntify building toccpant of to rreuiremets which thatb met responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate ofOccopancy. EXHAUSTHOOD(W /DUCT CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BTU) _ Date RCeei t# HEATING UMT(OVER 100,000 BTU) TOTAL: 1 E a. VEMILATON FAN (SINGLE RESID) , ISSUANCE DATE A yyyt 6® City of WGK Wv�/� R ISSUED BY: BORER -COMP (31 IF OR 100,000 BTU) BOILER COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ.{T. Owner or authorized agent Date TOTAL OFFICE COPY