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21895APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification - Build ng Add res.: I ^ SSO s Ci. a, Il `1 PERMIT NO. 21895 nen ams one: I— ,S FQ_%jtyr S�'� 6 Q CITY OF CUPERTINO•BUILDING DIVISION APPLICATION / PERMIT BUILDING -ELECTRICAL PLUMBING-MDCHAMCAL A � C-1 ^'b Contra cto's Name: Lie. No: CATEGORY CONTROLg . _.j_ 1v a'C9 AnhltM/Faginmr. Lie No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address: 1 PERMIT ISSUANCE Mob -Ci ❑ ❑ L�1 LICENSED beams under nde WS DECLARATION I bomb edl..mthat l iv Bans oftheerpressaions ofnd Pro Ch. Far 9 (mmmme licameh in force of Dlvifect.sion (the Buslnemand Profeeelone Code, and my license I,lCla s force and c. is Date Clam Lk.N Date Contractor ARCHITECT'S DECLARATION I understand my Id ... hall be used as public records. Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that Iamexempt ER DE Ga DECLARATION rBLicense Law for the lolbwing reason.(FecHm 76115, Buslnetand Profession. Cade: My city or countywhich requires a Parrott to mrstruct, alter, improve, demolbh,orrepair any structure statementithe fmsuc na, of t e file a actors dhtemeLa that he b r 9 (co d pursuant to the pro7000) of the that he iscar.&I res .art to Convector's urines Law (Chapter 9 (commencing with exempt 7000) of Divi. dlon3o(the Business and PrdembruCode)orthat heberempt Merefromand the basis for the alleged exemption. Any violation of Section 7611.5 by any applicant fora pernut.ubjectd the applicant to a civil penalty of me ..than Nv�e 1, asunded owner of he pr . I, adownerll otproperty,orhe employedwith wages r their sole compensation, will Bothe work and lheslructurc isnoHntentled or offered for Code: The Contractors License Law doerole (Set 7064, to alnow and f propertyand who not whodoerartsamrn Mmxlfedorough hleowale.If .. providedthatdoth suchpply oanownerofprough hiso nemplWilds e es, provided that Much Improvement is soil lntendrayearodcomplroffered tont, owner -y older ill have Improvement bwldwithlnoneyearofcomplrlbn,theowner-bullderwlll have man of proving that M did not build or improve for purpose of sale.). as owner of the property, am exclusively m Aracting with licensed otractors to mratruct the project (Sec. 7014, Business and Prof tamoru Code: Convector's License law does not apply to an owner of properly who builds, at Improves thereon, and who contracts for such plojects with a cgRjfactor(a) licensed pursuant to the Contractors License Law. IJ I am exempt under Sec B & P C for this reason APPLIANCFSRESIDENTIALIng JOB DESCRE'TiON _ • ..- "'SIF-- 1 PANELS XII -IOW AMPS OVER IOW AMPS SQ. Fr. FLOOR AREA A L E D 114 „y) j\AP �� SCJL �— S/SQ. FT. SIGNS ELECTRICAL SI'ECIALCIRCUIT/MISC TEMP META OR POLE INSI. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETSSWITCHFSNXTURES VALUATION / �, �O� ©� f. NEW RESIDENTIAL ELECTR SQFr. STORIES TYPE CONSTRLTC ION Liga) TOTAL: t QTY. PLUMBING PERMIT FEE OCC.GROUP RES. UNITS PERMITISSUANCE ALTER -DRAIN &VENT- WATER (G) FTAOD ZONE—AAPN FEE SUMMARY BACK FLOW PROTECT. DEVICE DRAINS. FLOOR, ROOF, AREA, COND. FIXTURES PER TRAP SANITARY Y N— R ECEIPT B Owner Data WORIOs1AN COMPENSATION DECLARATION ora ❑I hereby a(fiml that p have o mrturanc Of cOOYnI to copy certificate Workers Compersatlon Insurance macertlfled copy Mennf(Bac. 3olicyN G SCHOOLTAX Y— N RECEIPT N CAS G. SYSTEM -1 INCA OUTLETS PARK FEE V N— RECFL'rN GAS -EA. SYSTEM-OVER4(EA) Coman Y BUI LUING DI V ISI ON FE EB Certified copy is hereby furnished. ❑Certified ropy b tiled with the city impaction division. CERTIFICATE OF IXEMPEION FROM WORKERS' COMPENSATION INSURANCE (this lection need not M completed lithe permit b foramhundred dollars ($1 W)orlem.) I snot thato the Fora inaohmswork forwhichthispenult Isbass, I shall not employ any person In any manner ao d to bemma eubjeR to theWATER lawsof Gllfomis. Date CRGSE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE PAID he RCCf ttl ['F� J 4� CREASETRAP SEWER -STORM EA"FT WATER HEATER W/VENT./ELECTR E RGYY PAIApplicaNOTICE Retet til SYSTEM/TRFATINGWorkera'Comprnmllon NEW RESIDENTIAL PLMB._SQ.Fr. NOTICE TO AI'PLICANT:IL elver making This Certificate of Exemption, you Amid become aubjM to the Work.n' Compensation provbioru of the Labor Code, you moat forthwith comply with.uch pvi rosions mthb permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby af0rmthat then b ammtaction lendingagency forthe perform, ance of the work for which this permit is Issued (Sec. 3097, Civ, CJ Under's Name Lenders Address IcertlfythalIhave mad lhisappBdtlon and matethatthe above informationbarred.[agree I. comply with all city and muntyorellnancrs and tate laws relating to building construction, and hereby authotlu representatives ofthiscity to enter upon the above-mentiomd property for Inspection purposes. Agrn to save, Ind emolfy an d keep harmless the City of Cu pert Ino liabilities,judgments, coats and expenses which nay In any way accrue Cl In conaequenm of the grarding o(thle permiteiIITAIR TOTAL: 13UILDI G ••E Oo SEISMIC FEE O TOTAL: E QTY. MECHANICAL PERMIT. FEE FEE PERMIT ISSUANCE 4MECHANI ALTERORADDTOMECH. AIR HANDLING UNIT ITO 10,000 CFM) Rec6i tq(We) Pagainst SUBTOTAL!againstsaid HANDLING UNIT(OVER 10," CFM) ON TAX S� SevMpp lmnt/Contractor HAZARDOUS MATERIALS DISCLOSURE Will the applicant a, future building occupant store orhandle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.IZ and the I iealth and Safely Cade Section 25532(a)? ❑ Yes M No W6ltheapplicznt Ortulunebuildingompantuseequlpment articulates, which emit ha=rdom air contaminant. as defined by the Bay Area Air ality Management District? hvee read the hez.Nousomaterials requirements under Chapter 6.95 of the California Health&Safety Code, Sectiow255M, 25533 and 25516, I does na currently nequihavea tenant that it bay understneopmeandthatyto if he notify the ingoccupant r®or to lasuato notifytheoeate of ofthe rcquimmentswhich must be met prior to Issuance of a Certificate of Occupancy. EXHAUSTHOOD(W/DUCT) CONSTRUCT N TAX PAID: HEATING UMT(TO 100,000 Iff" Date R6CC1 ttf HEATING UNIT (OVER 100,000 BTU) TOTAL: VENIILATION FAN (SINGLE RESID) 1 •DATE _ / p Q1�?,t 'LolliNf of CU \ ISSUED By HOMER -COMP OLID OR 100,000 BTU) BOILER -COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ.R Owner or authorized agent Data TOTAL: OFFICE COPY