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23618C7, APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ usE RALL PnINT PFN nNI Y- - - Building PI Identifleation Bugd�yg Addresa:l - g U n r erre: PERMIT NO. -2.3618 i one: i¢AJ - 'CITY OF CUPERTINO-BUILDING DIVISION APPLICATION I PERMIT BUILDINGELECTRICALPLUMBINGMECHAMCAL A - caRtndora Lk. Na: CATEGOR CONTROLN Architect/Engineer.' Lk. No: QTr ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: - PERMIT ISSUANCE (I ❑ LAI—❑ LICF.NS EDCONTRACTOR'SDECLARATI N I hereby affirm that [cum Rcensed under provisions of Chapter9(commenc Ingwlth Section 7000) of Division 3 ofthe Busimssand Pro(esslonsCode, and my license is In full force and effect License Cbss � LIc.N Dale Contractor ARCHITECTS DECLARATION lunderatand myplareshallbeused aspubllcreronls. Licensed Pro(essiorul OWNER -BUILDER DECLARATION fromthe Contractor. License Gw(or the' I herewing meter. following reesan. (Section 7031.5, Business and Profess9on, Code: Any cityor countywhichrequiresapermittocostmcgalter, improve, demolish, orrepalr anystm=mprlortoiUb ance,alsorequlreatheappllrantforsuchpeimitto file a signed statement that he b licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(mmmentlng with Section 7000) of Divi. sion 3 of the Business and Professions Cade) orthat he is exempt therefromand the basis for the alleged exemption. Any violation of Section 7031.5 by any a civil penalty of no othan applicant fora permit subjects the appilcantro mre five hundred dollars CISH. o❑ I, as owner of the property, or my employees with wages as their sale compensation, will do the wark,and theatructure 6 not Intended or offered for .Is(Sec 70" Buamessand Professions Code: The Comnadoes License Law does not apply to an owner a property who builds or improves thereon, and who does such work himself orthrough his own employees, provided that such re Improvements anot Intended oroffered Tarsale. If, however, thebulidingor Improvement bsold wthinoneyearofcomplmiorytMo ner-bu0derw111 have thEI of proving that he did not build or Improve for purpose of sale.).- LI I, as owner of the property, am exclusively contracting with licensed contractors to con,tmet the project (Sec. 7094, Business and Professions Code: The Contractors License Law does nat apply to an owner of property who Wilds or Improves thereon, and who contracts for such pkajeds with a cq➢I et (a) licensed pursuant to the Contractor. License Law. L,J I am exempt under Sec. B & P C for this reason APPLIANCESRESIDENTLAL - PANELS JOB DESCRI'IION ' —}�v`�� ` ' z `YJ ' 201 -IOW AMPS OV ER 1000AMPS SQ. Fr.HAOR AREA $/SQ.FT. �.� Try 6•✓ ATIOII I © 7a d 0 l SIGNS ELECTRICAL SPRCIALCIRCUIT/MISC - TEMP. MEM OR POLE INST. .. It POWER DEVICES SWIMMING POOL ELECTRIC OUTLETSSWITCIiESF[X'1'URES NEW RESIDENTIAL ELECTR SQ'Fr. . STOW LS TYPE CONSTRUCTION' ' OCC.GROUP RES. INET, 'TOTAL: QTY, PERMIT FEE ,PLUMBING PERMIT ISSUANCE - .1 - '' ALTER -DRAIN Is VENT- WATER (EM plgpp ppNE APN BACK FLOW PROTECT. DEVICE FEE SUMMARY Owner Date DRAINS FLOOR ROOF, AREA, COND. FIXTlR9E4 PER TRA[' /b SANITARY Y_.N_ RECEIPT N WORKMAN COMPENSATION DECLARATION ❑I. hereby affirm that I have a certificate of cement to self -Insure, ora certifiatea( Workers'Compen,atlon lmunnceora cerHfled copythereof (Sec, 3800, Lab Policy If Sc[100L TAX Y N - RECENT N GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N RECEIPT III ' Co,myany ,LL��__yDD��..::shNed copy b herebyth thehed. 1$certlled copy b (fled with the city inspection division. YYY�YYi'''"'�^^^" CERTIFICATE OF EsEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (Ihlesedian need no[he camplded if the permit b(orore hundred dollen (E100)orlessJ -' I certify that In the performance of the work for which this permit is baued, I shall not employ any person in any manner n cue to became subject to the Workers Compensation Laws o(GlRornb. Date Applicant NOTICETOAPPLIGNT:If, coker making [tib Certlflale of Exemption, you should becortn subject m the Workers' Compematlon provision, of the Labor Code, you muctforthwlthcomply with such Provskmorthla Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Thereby affirm that therebacon,tnctlon lending agency forth perform. ance of the work for which this permit Is Issued (Sec. 3097, Cie. C.) Leder'sName Leader's Address - - Icerti(ythetl have dth pBalbnan fethatthe above lnformatlon Is coned. I agreet o pl Ithallcityan untyardmancesandetatelaws relatingtobulld as aloe, and he authorizerepresentativesofthia city 'a've-rrentloned arty for Inspection purposes. (We) a t n v ; indecom an ep harmless the City of Cupertino againatlbb t ,' grrent.,mrtsa xpenseawhichmaylnanywayamue agalnstsa consequence. egrantlegol4hl.permlt. GAS -EA 9YSTEM-OVER4(EA) GREASE/INDUSTRL WASTE INTERCEPTOR BUILDINGDIVISIONFEES PCANCIIECK FEE PAID Date Remi t# . CREASE TRAP SEWER -SANITARY -STORM EA, 200FT. -ENERGY WATER HEATERW/VENT/ELECTR FEE Y N PAID . Date Recei t# , WATER SYSTEM/TREATING NEW RESIDENTIAL FILMS.. SQ.ET. TOTAL: BUILDING FEF_.,QQ TOTAL: --(fo SEISMIC FEE ELECTRIC FEE r QTYMECHANICAL PERMIT , - FEE PERMIT ISSUANCE - ALTFAORADDIOMECH. AIR DANDLING UNIT Q010,(00 CFM) PLUMBINGFEE ,0 MECHANICAL FEE FEES PAID:' Date _ Reeel t# - SUBTOTAL• - AIR HANDLING UNIT (OVER 10p00CFM) CONSTRUCTION TAX ign,of Pant/ r or Data r.HA2A D S MATERIALS DISCLOSURE eappllant or fu building occupant store or handle hazardous V111. mate las defined by the III Municipal Cade, Chapter 9.IZ and the lic.It .ad Safety Coder -1 Yen , Section 25532(.)? Will the applicant or❑future building occupant use equipment or devlces which emit hazardous air contaminants as defined by the Bay Area Air ality Mamgement DisMd7 ❑Nohave read the hazardousrmterlals requlremenh underChapter 6.95 of the California Health&Safety Code, Sections 25505,25533and 25534. 1 understandthatlithe building does not currently have a tenant, that it is my respon,ibllitytonotify the occupant of the requirements which must be met�"ITY prior to Issuance of a Certificate of Occupa racy,Ow EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID: -• HEATING UNIT (TO 100,000 BTU) Date Recei t# HEATING UNIT (OVER 100N.,0W III TOTAL: VENTILATIO=(SINGLER�E�ID) ID) IVjUAN�ATE AO ,. 4 1992 OF WL)Y•CR•IIYU ISSUE ;* v\V' BOILER-COTU)Yas BOILEa-COM1)MAY NEW RESIDESQ.FT. neroraulhoriudageat Date.In,� NOTAL: OFFICE COPY