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21463APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification 0ullding Address � s. cR' _ I` PERMIT NO. 21463 secs ante 4 t .p'� nnnneWW CITY OF CUPERTTNO-BUILDING DIVISION APPLICATION /PERMIT BlBLD1NGaFCTRICALPLIJMBING-MECHANICAL A ,� l L l L cents oar N : BNS L¢(GQ CATEGORY CON'IjRR./ ILS L Architect/Fs neer. LM. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add.,:(17"7 .,ZrA Dr. E]_ ❑ ❑ PFRMITISSUANCE L'zx LICENSED ONTRACTOR'S DECLARATIONlie I hereby affirmthat l am licensed under provisions of Chapter 9(mmermc ingwlth Seciion70M)of Divlelon3 orlhe Buelnessand ProresslonsCode,and my license is In full f and effect License CWss-___LION Z Date Contractor ARCHITECTS 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 Lirenm Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which require a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant forauch permit to rile a signed statement that he h, licensed pursuant to the provision of the Contractor'sLicense law(Chapter9(cormnencing with Section 7000) of Divi- 810.3 ofthe Business and Professu aCode) orthat he is exempt therefromand the basis for the alleged exemption. Any violation of Section 7ML5 by any applicant fora permit subjects the applicant to a civil penalty ofect morethan five hundred dollars (5500). �I, as owner of the property, or my employees with wages as their sale compensation, will Bothe work, andthe structure isnot Intended or offered for .in (Sec. 7044, Business and Professlons Code: The Contractors License Law does not a ppiy to an owner of property who bunds or improves themes, andC:9/1 who deve..ch work hlmseRorthrough his own employees, provided that such improvements are not Intended oroffered for sale. If, however thebuilding or Improvement lssoldwithln oneycarofcomplMion,theowner-bullderwlll have the burden of proving that he did not build or improve for purpose of sale.). F1 4 as owner of the property, am exclusively contracting with licensed contractor to conetruct the project (Sec. 7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property whopLTEt-DRAIN builds or Improves therms, and who contracts for such plo)ec8 with a gaqactor(s) licensed pursuant to the Contractor's License Law. c LJI am exempt under Sec. B k P C for this mason APPLIANCESRESIDENfIAL JOB DESCRR'HON a^-'• L PANELS 201-1000 AMPS OVER 1000 AMPS SQ. Fr. FLOOR AREA S/SQ. Fr. SIGNS ELECTRICAL ' SPECIALCBRCUIT/MISC 4 TEMP. METER OR POLE IN EQ FEWER DEVICES 10 SWQdA9NG POOL ELECTRIC VALUATION Qda r , OUTLETSSWI7CILF_SFIXTURES l NEWREEDENTIALFLECTR SQ.FT. STOWFS _ TYPE CONSTRUCTION —SIC T QTY, PLUMBING PERMIT OCC.CROUP RES.UNITS ' p ITISSUANCE 1'1 l L�� k VLNT-WATER (FA) FLOOD7DNE APN s[[J BACK FLOW PROTECT. DEVICE FEE SUMMARY S OR DRAINFIDROOF, AREA, GOND. FIX'NRF_S PER 77LVa fb �U SANITARY Y N_ REC©T I s Owner Data WORKMAN COMPENSATIONDECLARATION - ❑I hereby affirm that I have a certificate of consent to self -insure, or a certificate ofWorkers'Comperuation Insurance or a certified copy thereof (Sec. 3800, Tab C.) 1'diry N n SCHOOL TAX Y N RFAEB'r N GAS EA.SYSTEM.I INCA 0IJTLETS PARK FEE Y N RECERrr N GAS EA. SYSTEM -OVER 4 (EA) Com any 6 .G Jp I Bless copy V herc�iy ed, Certified copy is filed with the city Inspection division. CERTIFICATE OF E(EMPr10N FROM WORKERS' NSURANCE INSURANCE Qhiesecilon need not be completedpermit Eulorohundred dollars (f1I conifess.) Ill not that emIs ploy anPersonIperformance anof y I shall not employ any person In any runner n u m become mbjeci to the m nnerwork so a to b co Bert subjeit is ct to the Workers Compensation Laws o(California. Date Applicant NOTICE co APPLICANT: a after makingthis tationlpro e(Exemption, Lyons of the Labor should become subject to the Worker' Compensalon s or this Code, you must forthwith mmply with such provisions orthi. permit shall be dmmm revoked. CONSTRUCTION LENDING AGENCY Iherebyaffirm that there is a mnstructlon lending agency for the performance of the work for which this permit Is issued (Sec 3097, Civ. C.) I.rxice. Name Lendae. Address I mrtifythat I have read this applicalionand nate that Neabove Infarmatlon iscorrect. Iagreeto complywlth all dlyand countyonllnancea end sate laws relating to building construction, and hereby authorize representatives of this city to enter upon the above�mcntloned property for inspection purposes. (We) agree to save, indemnify an d keep harmless the City of Cupertino against liabilities,} adgmenb,eeatsan pen sea which may In any way accrue against old City In ronaxryence of granting of this permit zz`= I it 9� BUILDING DIVISION FEES GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE PAID/i{�'+jCJ >/Q� Date Recei tit �` �+ GREASETRAP SEWER -SANITARY -STORM EA. 200FT. WATER HEATER W/VENT/aECTR ENERGY FEE Y N PAID Date Recei tR WA.IER SYSTEM/TREATING NEW RESIDENTIAL PLMB. _SQ.FT.. TOTAL: -.BUILDING FEE SEISMIC FEE t, l QTY. MECHANICAL PERMIT FEE PLUMBING FEE Lb, o MECHANICAL FEE PERMIT ISSUANCE FEES PAID: ALTERORADDTOMECH. Date Recei tk P AIR HANDLING UNIT (1010,00) CFM) SUBTOTAL: ' AIR HANDL NG UNIT OVER IO,OWCFM) CONSTRUCTION TAX Signatuso Applicant/Contfact r Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material a defined by the Cupertino Municipal Code, Chapter 9.1 2, and the I Iealth and Safety Code Sectlon 2.5532(a)? ❑ Yes MN. Willtheapplicant orfumrehuildingoccopantuseNuipment ordevim which coat havrd...air contaminants a8 defined by thcExy Area Air Quality Management District? qYea N No havcrcad teeth& ousmrterialsrequl25S05, under Chapter 5.95 of sheerstand thatto Heif alth kS.fetyCode, otcuru25505,ve atenad25534. , that undemmndyto notify thfy the occupant of t e requiyhavea tenant, that b met reaponsibs a ce na Bythe Occup ontofthercqulmmente which must be met prior to issuance ofd Ccrti(late ofOttvpanry. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HEATING UMTIM 100,000BTU) - Date Recel 1N HEATING UNIT (OVER 100,000 BTU) TOTAL: VENDIATIONFAN(SINGLE RFSIDI ISSUANCE DATE ��1I1t W`r LSSUIiD 0 : BOILER -COMP OHP OR 100,000 BTU) BOILER-COMP(OVQR 100,D00 BTU) NEW RESIDENTIAL METH, rQ.FT. Owner or authorized agent Date TOTAL OFFICE COPY