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20292APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Pm'c<t Identification Building Address: PERMIT NO. /1 ^ /� n 10 �s r s Re it/ - G O 292 wnare sine:aiLiU "f�iip �ona CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT _ _ A C°nnctor'sname: Liciyca"°. BUILDINGE.ECnUCAI.PLUMBING- I HANICAL CATEGORY CONTROL N Arehltea/Engineer. Lie. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: fO PFRMITISSUANCE /�,VJ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby afit=that l am Bernard under provisions of Chapter 9(commenc ingwlthSection7000)ofDiA,ion3ofthe Buslnessand Profevi.n,C e,amdmy license is In full force and effect. LicenseClam Zontr Date Contractor APPLIANCE-RESIDEN'ML PANELS ]OBDESCRIPTION 701-1WO AMPS ARCHITECI`S DECLARATION I understand my plain shall be used as public records. !rr OVER IOW AMPS SQ. FT. FLOOR AREA $/SQ.FT. SIGNS ELECTRICAL Licensed Professional OWNER-RUILDER DECLARATION' I hereby affirm that I sin exempt from the Contractors License Law for the following rcason.(Section 7031.5, Business and Professions Code: Any city or cmntywhich mquires a permit toconatmcL alter, improve, demolish, orrepair anystmcturc prlorm its issuance, aiso uxquireathe appBcan[fonuch permit to file a signed statement that he b licensed pursuant to the provisions Of the Contractor's License Law (Chapter 9 (no.scing with Section 70M) of Dlvl- sion3ofthe Business and Professions Code) orthat he Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70X5 by any applicant for a permit subj is m the applicant to a civil penalty of not ore than fve hundred dollars ($500).✓t I as owner ofthe property, or my employees with wages as their sole e mpensation,willdo the work and the structure isnot intended Or offered for sale (Sec 7034, Business and Prefeasiond Code: The Contracu,ex License Taw does not apply to an owner of property who builds or improve thereon, and who d°essuch work himself or through hisown employees, provided that such i iY t, in SPECIALC1RCUfT/MISC Taro TEMP. METEROR POLE INSf. POWER DEVICES SWIMMING POOL ELECTRIC [� VALUATION FP •a OUTLETSSWIICHESH%TURES . 00 NEW RFSIDENTIALELECIR SQ.FT. �STOIU[S 7YI'E CONSTRUCTION C OCC GROUT' RFS, UNTI5 improvements are not intended or offered for sale. If, however, the building or improvement bsold within one ycarofcompletion, the owner -build erwill have the*nJon of proving that hedid not build or Improve for purpose ofsale.). LJ L as owner of the property, am exclusively contracting with licensed contractors to construct the project (Soc. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who bu Wilds or Improves thereon, and who contracts for such pcujecs with a TO L: '• �. SV QTY, r PLUMBING PER I FEE----- PERMIT I55UAN AL3FR-DAMN & - p U55DzoN pPN oO,attn,ctor(s icemcd pursuant to the Contractors License Law. LII am empt\ nd� ^ B k P C for this mason a BACK FLOW PRO T. D CE FEE SUMMARY Owner I—S � WO AN COMPENSATION DECLAR O ❑I hereby affirm that I have a certificate of consent to self -insure, or a certificate of Workers' Compensation Inaomere, mea codified copy thereof (Sec, MOO, Ib C.) if DRAINS R F,ARE&CIOND. SANITARY Y_ N — RECEIPT It FIXTURES 7A Tex SCHOOL TAX Y N RECEIPT N GAS E.A. SYSTEM-11th .40UTLETS PARK FEE Y NPol_ It Cram any ❑P Certified copy b herebyturnbhed. ❑Certified ropy b (Tied :vith the city Inspection division. , GAS FA. SYSTEM-OVER4 LEA) GREASE/INDUSTRL WASTE INTERCEPTOR BUILDI�NC DI VISION FEES PLANCHECKFEE GREASETRAP CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thbsectitnneed net be<omplow lfthe permit isforone hundred dollars WWI me l„t.) lanot emptor anypfore, inan theworkmanner forwhwast beco permitctto the I shall not employ any person in any manner at u to become subject to the W an Compensation lawn of Gllfomld. Date Applicant PAID Date RC'cei t# SEWER-SANITARY-STORME,. HAFT. WATERHEATER W/VENT/0-ECTR ENERGY FEE Y N PAID WATER SYSTEM/TREATING NEW RESIDENTIAL PLMB.__SQ.f•7, NOTICE TO come. bICANT':I(Worl making this sationluteof Exemption,you Labor .houlCude, become subjecttothe Workers'such prsatl°nprovbis permit Code, you swat forthwith comply with such provblona orthb permit shall be d`xcefd rev°ted co"srgurno s LENDING AGENCY Ihercbya(flrmthauhere bacomwctlon lending for perform arcs of the work for which this permit la issued (Sec. 3097, Civ. C.) Lender's Name Lender'sAddress I certifythatl have mad thsapplication and etatethatthe above infomation bcorrect. Idgere tocomplywith all cityand county ordinances and state laws tO building construction, and hereby authorize reprearetativn of this citytoenterupon the above-mentioned property for Wpection pu rpmae. (We) a to save, indemnify an d keep harmless the City of Cupertino against IBtles,ydgmen[s,cases and expenses which may In anywayamrue ag na a dCity cone sof th anting of this permit. < Dale ReCei t# TOTAL: BUILDING FEE TOTAL: SEISMIC FEE FEE ELE!ICAL , QTY. MECHANICAL PER FEE PERMIT ISSUANCE z_�a PLUG FEE MECFEE `O FEESrelating - ALTERORADDTOMECH. AIR HANDLING UNIT (TO ]0,000 CFM) RCCCIFt# SUBTOTAL: AIRHANDUNG UNIT (OVER 10,t10OCFM) CONSTRUCTIONTAX S na o(Applicant/Comcacior—� Date HATARDOUSMA ERIALSDISCLOSURE IXHAUST HOOD(W/DI1CT) �', CONSTRUCTION TAX PAID: HEATING UNIT (TO ]W,00007L0 Will theappllcant or future building occupant store or handle haealloua fin material as deed by the Cupertino Municipal Code, Chapter 9.12, and the Ilealth and Safety Code Section7553I(a)7 EDyesN No Wlilthe applicant°r home, building occupant use equipment°rdevices which emit hazardous air contaminanb as defined by the Bay Area Air Quality Management Dis a7 4ye�° Date RCCCi I# HEATING UNIT (OVER IW,000 BTU) TOTAL: DD VFNILATIONFAN(SINGLE REBID) ISSUANCE DATE p PAID BOILFR{OMP 0HPOR IW,WO BTU) havercad the hazy sreateeiab requiremonts under Chapter 6.95 of the California Health A Safety Code, Sections 7550.5, 25573 and 25534. 1 understand that lfthe building does not currently have a tenant, that It is my responsibility to notify the occupant of the requirements which must be met prior to Issuance of a Certificate of0ttvpanry. MAY 1 5 1990 Cit!/ of r!in,irtipo BOILER-COMP(OVER 100,000 BN) NEW RESIDENTIAL MFCH. SQ.FL � ISSUEDBY: ��4, v C,(�x Owner or authorized agent Date TOTAL: OFFICE COPY P