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S 2503CLC. y�i• aa� xX�0 ul- F. z f= CI' a3 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO -NIrr, IICAi rr:RMIr NO. BUILD NC. h;I.ECTN BUILDING DIVISION APPLICATION/PERMIT I'hUMNINC-NF.CILAN;CAL."'^ S 2503 COOITTACT: 1PHONE: K^yZG✓5- LLVt/Y^iX/ 0' LICENSED CONT'RACTOR'S DECLARATION lichy alTrrn that 1 am Installed under provisions :f Chapmr 9 bom,nencing with Scni:n ]1111111,d Division J of the Ifilsiness and 14oelcssinns Gale, and Iny license iN in Enl(arceand effect. - -)/ LiI Clue Ia,# nate Cumram:r _iJwi16V& • Ftaa/Y ❑ Consultant Fees Paid by Applicant (Initial) OWNER -BUILDER DECLARATION 411c affirm Ilial 1 an exnnpl Iron, he Conlranur'n I.imnse Low for the following reason. (Section 7011.5. Business and Prnfecsi m, Code: Any city or county which requlrer a permit n, ti amel. aIle[ impnn'c, demolish, or repair any sombre print to itse,also y the trod team fr. such It Fir a signedstatement Iher lie I a Ip In. p t the Curnearlin 1 ' 1,11,((:hap",9 bournanci,ywlh Suoo 1]000) of Division 3 of like Business ad Poce,itak,Cale)or that he is c 2mpt therefrom and the basis for the alleged conniption. Any violation of Section 7031.5 by any ,p,li.ct for a pennil subjects the applicant to a civil penalty of sol more firm live hundral dollar MINE, 0 Las owner of the progeny, or my employees with wages as their sole compensation, rill do the work, and the structure is net idended proffered palate (Sec. ]BW. Bus ineu and Professions Cade: The Control License law does col apply to an owner of property who hadds or improves Ihcrci n, and who does such work himself or through his own emgloyees, provided Wm smh improvements are nn, intended :Ioffered Toil sale. IL however. the building or improvement is sold within one year of conhpletion, the poer-builder will have the burden of proving that he did not build or improve for pur- w, of ams.). ❑ 1, as owner If the pngery, an, uxemsively c:mr®king whh licensed counsel In nswet the project (Sac. AW. Business and I'mfexsiuns Cale:) The Counci s Lb wKLaw d,xs not applyman owner of progeny who builds orimprova thereon.and QTY. ho umonats for such projects with n a:nnYcro(s) licensed punuanuo the Centrwmr'a License l.aw. ❑ I ran exempt under Seo .11& P C for this mason Care, Date WORKHR'S COMPLNSA'I'ION DIiCLNtAI'ION 1 hereby off m, under penalty of pequry line of the following declarations: 1 have and will maintain a Carbonate ofConunn: self-imure for Workck's Carl sation, as provided for by Sectio 3](Xk:f the Labor Code. (:r the performance of the work fur which this pnmn IX issued. n I have and will maintain Worker's Compensation Insurance, as aNtocal by Section 37W of the "bra Cale. for the performance ut the work for which this permit is issued. My Worker's C:mNhskdk Insurance cmrier and policy:, Cosier: (�t�i1 I %� policy No.: •a "m CERTIFICATE 017 HX L, F ION FROM WORKERS' COMPENSATION INSURANCE, Obis tion need not bec:mplmal ifthe pemhit is for one hundred dolLms(SHXII or Ices.) I land, Iles In the perfonnanm o0hawork list which Ostrom, is vand, l atoll not empty any' em" many ma .. to wnyu�i nesahicclmthe Workers 'Co,npen- xnkicnLawsnfColifnml 4'%%' Ytl Applicant Q`-IL/G•QI�—.�/AN��IL� NGf ECC 10 APPLICANT: If. of". making this Cendicam of lisemptin I you should become subject to the Workers Compensation provisions ul the LubOr Cale, you (lost forthwith comply with such provisions or this pennil shall he deemed revoked. C'ONS'1'RUCI'ION LFNIDING ACHNCY like1 hereby affirm that mete i+owed (See. 30 Co. aguncY f alis perf rmance nl' Le de rs for which this permit is issue) (See. 3097, . C.) Lenders Name Lender's A l, 1 certiNfy mal I have .it cis Itppncarnn and Stam mal beal roo relat,t iot builder l agree m amply wW, all City and county oNinnndes and state lowswsH retto e QTY, hoodingeonsmsti,.and herebyaethunz proposes, Lives ofmicary to enter upon me above-methmom progeny for irspcnion keep Fa. (Wel ogres n, cove, and expert and keep harmless the City ofea lino said in colities,ju ce of the costs and expenses which may in any way accrue ugainsl said Cit in PLICANI Nthe RSTA g Sthispennil. APPLICANT' UNDERSTANDS AND WILT. COMPLY WITH ALL NON -POINT SWRCE kIi0Ul.ICNS. Signature of Applicar, cm Ilmc HA'/, RD S MATERIALS DISCLOSURE Will the nail nil no." a rc budding lamnpmn stare nil handle h rear oux combat us defined by the Cupertino Muni cipal C Chapter 9.12, and the Heath and Safety Coad., Section 25532(x)'! (] Ycs Will the applicant or future building occupied use c,upomd or devices which emit bmallous air commninams m�by the Bay Arca Air Quality Management ❑ Yes I have read the hmallous note " nyuidmdn¢ uamr Chapter 6.95 of the Crab funtia Hart,h & Safely Cnde, Sectio 25 05, 25511 and 11531 I underdand mak if the building d,e/�nncurm,ty by cc of xn1 lit ilixny l'eslumsthility to ami l y thc,mcapxm :flue repy/!I nalswhiprmu. In O$ lo'Lsuance of a Comillemeof Occup,,,,, ELECTRIC PERMIT' HRMI'r ISSUANCH APPLIANCES - RFSIDHNHAL PANELS U11'r0201 OVER 1000 AMT'S SIGNS EIXCI'RICAL SPECIAL CIRCUIT/MISC. I LMP. alp risk OR POLR INST. IIOWER FIRVICIS Ae SWIMMING POOL ELECI'IXIC (YU"RETS - S W ITCHES - FIXTURGS FFI: —1g-9 -'( ❑ 1 E'220 BUILDING PERMIT INFO BLDG ELECT' PLUMB MECH Z�-, GY ❑ E2/ - JOB DESCRIVHON RESIDENTIAL SQ. IT FLOUR AREA [� Q g -71LI (/ / OSFDWL ❑ KI'T'CHEN RIiMODIiL CADDITION 0PLUMBING RE-PIPH CMUCI'6UNIT CSTRUCTURAL ALL ER - DRAIN & VIiNT- WANR IEA) MODIFICATION CINTERIOR OCHIMNU REPAIR IMPROVEMENT 0SWIMMINGPOOIS 0 HATH RIiMODEUREPAIR 0 DEMOLITION C OTHER 'TYPE CONS IR e AJ �ID 3 o Z IIXTU ' kA COMMERCIAL: 0 NEW BLDG/ADDITION 0 DEMOLITION Ll. ,ANT OFOOD SIiRVICE IMPROVEMENT ❑ OTHER NIiW 12F.SIDIiNI'I .IiLIiCJ'k SQ Fir SQ. IT FLOUR AREA [� Q g -71LI (/ / PLANCHECK IEE $/S( oT -Pit , P •1F ITE pINMIT ISSIIANCL ALL ER - DRAIN & VIiNT- WANR IEA) VALUATION -2-2— / © O HACK FLOW I'ROTECr. DEVICE DRAINS- FLOOR, ROOF, AREA. OR INV PEE STORIES Z OCC. GROUP 'TYPE CONS IR e AJ �ID 3 o Z IIXTU ' kA GAS- STEM C. J'LIiTS GAS - E . 'TF,M-OVQR E Jq99 CrRRA SE IN PLANCHECK IEE O ( p SHIVER -S RY-S'r ItNP.RGV FEII WATER HH W/VENI'/llR OR INV PEE WAIFR SYS 'I'INUT RIiAI'INC, WATER SERVICE NEW RESIDFN'HAI. PI.MH. SQ. pr Dole Receipt p 10TAL: TO 1'AL: BU .DING FEE 2-6 MECHANICAL PERMIT ITC SE MIC hili I'IiRMiT ISSUANCE n Til RIC IUiE 12-4 ALTER OR ADD TO MI:CH. 2 PLUM NG IEE AIR HANDLING ON[[ (TO IiLXX)CIM) MHCHAN .ALFEE 2l AIR HANDLING UNIT IOVF-R 10,1XIDCPM) CONS] 'RUC7HON']AN 17XIIAUST HOLD (W/DUCT) HOUSING MITIGATION FEE. 1117ATINCI UNIT (TO 100,00n H'I'W I IHATING UNIT (OVER 10,0(10 It I HE PAID VENTILATION FAN (SINGLE RE5111) nam Receipt a MOILER -COMP (31111 OR 1010,(XX) B'I'U) 'TOTAL BOILER - COMP(OVFR 100,01X)1I1'U) AIR CONDITIONER I , U NCE DATE NEW RESIOCNT1ALMECH. SQ IT. OFFICE