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20248• oz o� 0z;:8 FSq�aa w �ga555�� 5�0 �$S • R N LU CL D 2 00 LL ~ OW }a H N Z U- 100 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY-. Building Procd identification - Building Address: V2 // a taltf'ava - PERMIT NO. 02 ^ 8 G!f era / y}— �e [•, CITY OFCUPERTTNO-DUILDiNG DIVISION APPLICATION / PERMIT qT $/711`0 7~ l ( u Con a Cie Na Arahl glneen Lk. No: BUILDINGS,ECTIUCALPLUMBINGMECHANICAL CATEGORY CONTROL M 6 g .7 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO -. 1� ❑ Address: fB0 PERMITISSUANCE Z,.i� LICENSED C TRACTOR'S DECLARATION JQ� Ihereby affirm that l am licensed under provisions of Chapter9(comenenc- APPLIANCESwRESIDENITAL JOBDESCRIPTION ingwllh5ectlon 700Wo(Dlvlsian3o(the8udnessand ProfessionaCode, and my her- icenLice0., i—yo GOnladar ♦ 4 L'- 0., ARCHITECTS DECIAMTION I understand my plans shall be used as public records. 1 ,']_ , 201-1000AMPS OVERIOOOAMPS SQ. FT. FLOOR AREA F/SQ.FT. SIGNS ELECTRICAL Licensed Pmfeaskmal - - SPECIALCERCUIT/MISC - OWNER -BUILDER DECLARATION I herebyd rrothat I am exempt fromthe Contractor's License Law for the TEMP. METER ORPOLE INST. followingreason.(Section 7th L5, Business and Professions Code: Any city or =ntywhich requbes a permit tommtmd, alter, improve, demnlbh,ormpair anystmumpriortolbb amt alserequimtheapp0antfwsuchpemdtto file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES SW[MMING POOL ELECTRIC Contradata License Lcaw(Chapter 9(commenMg with Settle. 7pD)uf Divi- sio.3 of the Business and Pdessiuns Ccde)orthd he is exemptthemfromand VALUATION the basis for the alleged exemption. Any violation of Section 70315 by any Applicant for a permit objects the applicant to a civil penally dot nmore than OUTLBTSSWITCIffSEKTURES re�o C ©1 o NEW RESIDENTIAL ELECTR SQ.FT. five hundred culls. (SM ❑ 1, as owner of the property, or my employees with wages as their Bole STORIES - TYPECONSULC'HON compensation, wi ldothe work and thestrodure Is not intended or offend for sale (5a. 7064, Busmen and Pdenions Cade: The Cont.c.e. License taw , does not apply to an owner of property who Wilds or improves thereon, and whodoessuch workhmuellorthrough hisownemplaym, provided that such Improvements are not intended oroffered forsale. If, however, lhebuildlng or TOTAL: OCC.CROUP RFS. UNITS Improvement bsold wllhinoneyearofcomplelen,theowner-W Rderwlll have t1,,Qurden of proving that he did not Wild or improve for purpose of sale.). LI L as owner of the property, am exclusively contracting with licensed ta14, contactors to construct the project(See. 70Business and Professions Code: QTY. PLUMBING PERMIT FEE FLOOD ZONE APN PERMIT ISSUANCE 1 The Contractor's License Law don not apply to an owner a( property who Wilda or improves thereon, and who contracts for such pRojects with a cgR(fadmr(s) licensed pursuant to the Contractor's License Law. j 1 am exempt under Sen .B k P C for this mason ALM -DRAIN kVENT-WATER (EA) - FEE SUMMARY BACKFLOW PROTECT. DEVICE QQTSI DF FEES DRAINS FLOOR ROOF, AREA, COND. SANITARY Y_ N_ RELET N OwnerDate WORKMAN COMPENSATION DECLARATION ❑I hereby ffum that I have • certificate of consent to selfdnsure, or a mmilateof Workers'Compessatlon Laurance ora mrifled copy thereof (Sec. 3800, Lab CJ Polity Y � O a FIXTURES PER TRAP SCHOOL TAX Y_ N_ - RECEIPTNN r�9 GAS EA. SYSTEM -1 INCA OUTLETS Gs PARK IEE Y N_ DING a CAS FA.SYSTE.(-0VER4(EA) Com y ed copy's hereby film shed. Certl(led copy Is filed.vilh the city Inspection dheidan. CERTIFICATE OF EXEMPTION FROM WORKERS' DI BUILDING DIVISION FEES GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE P,r /�/_/ MY I 12— �� (s GREASE TRAP COMPENSATION INSURANCE (Thisuation need not be completed lithe permit h (Drone hundred dollen SEINER-SANHARY-SIORM FA 2001tr. Dale Recei tIt WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N ($100)wless.) I certify that In the performance of thework for which this permit b Weed, WATER SYSTEM/TREATINGWorker' I shall not employ any person In any manner n as to become subject to the Compensation Laws of C+ilfomia. Date PAID NE'WRISIDENTLALPLMB. 9QF7. Applicant NOTICETO APPLICANT: IL after making this Certificate of Exemption, you shouldbecomesubjdi.the Workers'Compensationprovblensofthe Labor((']]ss Cade, you most forthwith comply with such provisions orthb permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Date Rece1 to � � �� R— 0� - -'ck, TOTAL: BUILDING SEISMIC FEE IherebyafOrm that there b a construction lendingagency for the perform once of the work for which this permit b issued (Sec. 3097, Civ. C.) Ia.der'sNAZ - Lender's Address eartlfythat I have mad thisapplication and date that the above Information Is correct. lagree to comply with all city and county ordinances and date laws - TOTAL: ELECTRIC FEE PLUMBING FEE r?rJ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID: relating mbullding construction, and hereby authodza representatives of this city to enter upon the above-mentioned property for Inspection purposes. (We)agree to save, Indemnify an d keep harmless the City of Cu pedino against liabilities, judgments, trots and expenses which may in any way accrue ALTERORADDTOMFLH. Date Recei tM P AIR UNIT (TOlO,WOCFM) - SUBTOTAL: agmnst said City In consequewe of the Starting of this permit. AIR HANDLING UNIT (OVER 10,000CFM) CONSTRUCTION TAX Slgruture of Applicant/Contractor Date IXHA(15'r HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CIO 100,000 BTU) Date ReceI t# Will the applicant or fu me building occupant store or handle barardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the I lealm and Safety Cade Section 25532(a)? ❑ Ycs M No - HEATING UNIT (OVER 100,000 BTII) TOTAL: VENTILATION PAN (SINGLE RFEIO) iSSSMVE DATE Willtheappliant arfuturebulldogompantmeequipment ordevices Mich emit herardous air conlamdnanb as defined by the Bay Arca Air ly MawgcmeM District? `y5 have read the hazardous materlala requiremenh under Chapter 6.95 of W 1 0 ppAA(( 4%5 •�� . is BOILER -COMP PHI' OR 100,0(10 BTU) BOILER-COMP(OVEt 100,000 BTU) the CelifomlahealthA,Safety Cod,Sectioru 25505,25533 and 25534. I understand that if the Wilding time not correctly have a tenant that It is my ' asl� NEW RESIDENTIAL MECH. SQS-T. responsibility to notify the occupant of the requirements which must be mat prior to issuance of a Certificate of Occupancy. ntMt O!/�r�•.q•�..,� ��sa� ISSUED OYUI.�II/Il P3..)tLJtl�""41 Owner or authorlead agent Date TOTAL: OFFICE COPY