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24198APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro et IdentlrlcationP"" Building Address: -7633 tiepih Eod sc wor NQ, 419 8 Z ,I, eSSE LIw ,255 196`79 CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDINGELECTRICALPLUMBINGM[CHAMCAL AA �— Contra 'a Name:.No: r\ S LIcOV �, CATEGORY CON7ROLM Archltm/Engines. Lie. No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Addrcu 1:1 1] � ❑ PERMITISSUANCE I hereby afLICENSED CONTRACTOR'S DECLARATION firm that l am licensed under provisions of Chapter 9(commene- Ingwllhse tion 7000)ofD1WNon3 ofthe Busicassand Professions Code, and my license la Into fofoe and k.#' Date -I I 1R Lam Date — / f - S' �ContraRor [TK"— Iyy61Ns/ ARCHITECT'S DECLARATION I understand my plateshlibeusea u public records. Licensed Professional OWNERhat I am -BUILDER DECLARATION B fromthe Contrators License Lw fort he 7wing .. Section 7031.5, followingreawn. iretron70)t$BustneolOd Profenba Code. Any city or rocoatot, alter, Improve, demolisher repair aantywhkh requires s issuance, any a signerettemor ethaa tit;alcensedso ursuarte, the tothe[fwachpermlte to file a etor's. License statement that he (Chapter 9 (commencing encing t it the proWlOru of the Mon 3oftheurines andPre9(romm.,the, witharmpn7000)of DWI- Mon 3.le fo Business and Pemptioa Code) orthat he f exempt 7EGIS by and the baeb far the alleged exemption. Any violation o(Setlan 7Q1L5 by any five undforapersES500etsthe appliranttoacivil pealty of not more flan flue hundreddollar.he pr. a, or he employee with wages r their woe I, as owner of the thereh not Intended or cense L for compensation, wusBothe work and ProfessionsCade: The Contractors Lamm Taw ale snot 7044, to show and f property improves that and docs not apply loan ownerorpapetywho own uilds employees, his ownemp, have et, the build isuch such who does encsuch am net mee intended or 4nprevement iarenaintended earofco rorsale.theo vep gder Wingw Improvement V cold within oaycarofcompltion, the owner-bunderwill have the burden of pit that he did not bund or improve for purpose ofsale.), u I, as ..or of the property, am exclusively contracting with licensed The Co tr tocoatotl the w doe(Seo app) to am o and of proioa Code: The COor imprer Luther Taw red net apply et an owner of property who builds or Improve themoa, and who roMvata for each p(ojem with offoff1c=1exempt under pursuant the Contratore License Law. 1c=1 am exemp under Sec B k P C for Nb reawn APPLIANCES -RESIDENTIAL JOB DF3CR MON /1� 9 (/_LV.. TL PI I � PANELS 101-10DO AMPS OVER1000AMPS SQ. FT. FLOOR AREA f/SQ.FT. � N A L C D IN N Vf c E V I{{��////�/7� pp.�� f� ©M 1 U tl Lam, Np••fl i ATE �r/ZZ SIGNS ELECTRICAL SPECIAL CrRCUIT/MISC' TEMP. MEERORPOLE INST. POWER DEVICES SWIMMING POOL ELECTRIC ti VALUATION OUTLETSSWITCHESFIXTURES NEW RESIDENTIAL ELECTR SQ.FT. STORES TYPE CONSTRUCTION TOTAL: QTY PLUMBING PERMIT FEE PERMIT ISSUANCE !ie ALTER -DRAIN Is VENT- WATER MA) OCC.GROUP RES. UNITS FLOODZONE APN FEE SUMMARY BACK FLOW PROTECT. DEVICE DRAINS FLOOR, ROOF, AREA, COND. pps.{UgEce pgg TRAP SANITARY Y_ N— RECOPI R Owner Date WORKMAN COMPENSATION DECLARATION ❑1 hereby affirm that I have a certifieste of consent to aelt-Insure, ora mdlflmteofWorkets'CompntuaHonlmuranmara certified ropy thereof(Sec. 38M, Tab C.) Poliry Y - SCItOOL FAX Y_ N_ RECEIPT N GAS EM EA. SYST-1 INC40ULLEfS PARK FEE Y N RECEI N C Corn ny Certified GAS EA. SYSTTM.OVER 4 (EA) DING DE BUILDING DIVISION FOES [] copy Is hereby thMsh Certnled copy E (14d with the city inspection division.CREASE/INDUSTRL city CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Rhissetlan need out be completed i(the permit V (Drone hundred dollars .fSI IU Modify thatpenult c Rued, Ill net mplo any Phe erson, I shall net employ any person in any mannerso u to become abject to the I an the work foras to become Workers Compensation Gwe a(Gil(Omla. Data AppliNOTICE NOTICE co AI'PLIC t to the, after making thea Certnlpre of Exemption, you Code,shoulyou mus abptto the Workers'Compewtiuns,arthloarrthe s Gbor Cello you muc(arthwith comply with suchpreWsba artists permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Iherebyatfirm that there is a construction lending agency for the perform an. of the work for which this permit la blued (Sec 3097, Civ. C.) Tender'. Name Lenders Add m. I certify that l have mad this application and state that the above information Is correct. I agree to comply with all city and county ordinances and nate laws relating tobuilding construction, and hereby authorize representatives of thix city to enter upon the above-mentionad property for inspection purposes. (We) agree to save, Indemnity an d keep harmless the City of Cu Faction aga Wt llabillties,judgments, mats and expenses which may in any way arrow aga mat aid Cl In ronsequenceo the granting of this permit. WASTE INTERCITTOR PLANCI'JECK FEE PAID Date RC i t# GREASE TRAP SEWER -SANITARY -STORM FA. 200E T. WATER HEATER W/VENT/O TEE ENERGYFEE Y N — Pplp Date Remi t# ATER STEM/TREAIIN'G RESIDENTIAL PLMB. SQF1'. TOTAL: BUILDING FE OT SEISMIC FTE ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FTE MECHANICAL ITE PERMIT ISSUANCE FEES PAID: ALTER OR ADD TO MECH. AIR HANDLING UNIT CED 10,000 CFM) Date ReCei f# P SUBTOTAL: AIR HANDLING UNIT (OVER l goon CEM) CONSTRUCTION TAX Signs torytoApplicant/ ontra<or Date HAZARDOUSM :RIALSDISCLOSURE Wmlltheappl or or future building occupantstoreor handle hazardous uDate miderial as definby the Cupertino Municipal Code, Chapter 9.12 and the I Ira llh and Safety Code Setion 15572(a)7 ❑ Yes No Wnllheapp11on1wuturebulldingoccupant use equlpmentordevices which emit havardous air contaminants as defined by the Bay Area Air Quality Management Distant? 4Yes n No haveread Health afet naterials rcqulrcrrenbunder ndCha 25546.95 ofBOILER-COMP(OVER the Glilomla Health & Sa lety Cade, Sections 8$05, 75537 and 15534. I understand that lithe building does not currently have a tenant, that it is my mapoaibsutyto notify the icapant of the requirements which moat be rret prior to Issuance of Certificate of Ocapanry. 9—�i EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BI]) T Receipt TOTAL HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE READ) ISSUANCE DATE pq r q SEP d� 's7i/ 199?I C ITr Y ISSUED BY: BOILER -COMP OHP OR 100,000 BTU) 100,000 BTU) NEW RESIDENTIAL MECH. SQtT. - suruagent Date TOTAL: OFFICE COPY