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24223APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY building Project Identification Building Address: PERMITNO. 24223 �5 S / 2 . core e. A A �p CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUILDING-ELECTRICAT TLUMBINGMp.CHAMCAL �a cont.eo :Name: c.Np: CATEGORY CONTROLX Architect/Engtnser. k. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO —/ Aa j, E3hBrlssuANCE ❑ ❑ ❑ LICENSED CO RA OR'S DECLARAT N I hereby affbm that l am licensed under provisions of Chapter 9(cxmmenc ingwlth Seciion7fX0)of DiWsion3ofthe Budnemand Professionscodeand my I= b In (u ores and effect. APPLIANCESRFSIDENf1AL PANELS I JOB D[SC TION LIreryX CIynLk X;"N7I!3+n�9 Date%ZL Contras[,,�yJ Q�/jcaD UP TO 2DO AMPS N11-1000 AMPS ARCHITE(PS DECW ATION I understand my phnsaha8 be used m lic records OVERI"AMPS SQ. FT. FLOOR AREA $/SQ. FT. SIGNSELECTRICAL Licensed Professional SPECIALCIRCUIT/MISC OWNER -BUILDER DECLARATION I hereby afRrmthat I am exempt from the Contractor'sLicenseLaw for the TEMP METER OR POLE INST. following reason. (Section 7033.5, Business and Professions Code: Any city or rountywhich requ ma permit tommtmo, alter, bnpmvq de=lbh,ormpair anystmciure pdortolts issuance, also requlresthe applicant for such permit to ilk a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES SWIMMING POOL ELECTRIC Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi- don3 of the Buslnessand ProfessionsCode)orthat he it exempttherefromand VALUATION the Wait for the alleged exemption. Any violation of $Ration 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of not mom than OUTLETSSWITrHESFIXTURES five hundred dolls.($.500). I, as r of the property, or my employees with wages as their sole compensation, will do the work and the structure brat intended or offered for NEW RESIDENTIAL ELECTR SQ.FC. STORIES TYPE CONSTRUCTION sale (Sec. 7044, Business and Professions Code: The Contractor's License law does not a pply to an owner ofproperty who Wilds or improves thereon, and whodoessuchworkldmse8orthtough hlsownemptaym, provided that such OCC.GROUP RES. UNITS TOTAL: improvements arc not intended proffered for sale, If, however, thebuilding or Improvement b suld within oneyearofcompletion, the owner-bu Ilder will have t1IRtiurden of proving that he did not Wild or improve for purpose ofsale.). LJ L as owner of the property, am exclusively contracting with licensed cont.don to construct the project (Sec. 7044, Business and Professions Code: QTY. PLUMBING PERMIT FEE FLOODZONE APN PERMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who Wilds or Improves thereon, and who contracts for Such ptojects with a cgBS�+cmr(s)Ikemd pursuanttothe Contractors Limme Law. LJ I am exempt sandy �� B h P C for this re ALM -DRAIN k VENT- WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE ' DRAINS FLOOR ROOF, AREA, COND. SANITARY RECEBT X Owner " Uate WOR KMANCOMPENSATION DECLARATION f_11 hereby affirm that I have a certificate of conaem to self -Insure, or a certificate of Workers Compensatlonlnsurance or a certified copy thereof (Sec. 3800. Lab CJ ��/��'� FIXNRFS PER 7RA1a SCHOOL TAX Y N RECEIPT N GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N — RECEB'1'X Po"i I Com anv/��"!j �Certmpy hemby turnl ed. RLCertified copybfilcd with the city,_P_,On division. CASEA. SYSTLALOVER4(EA) BUILDING DIVISIONFRI:S CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE GREASE TRAP CERTIFlCATE OF IXEMPFION FROM WORKERS' COMPENSATION INS..ANCE Rhes sdion need nor be completed if the permit is for one hundred dollars (5100)^rleas.) 1 comlythat m the performance of the work forwhich thls pem it b issued, PAID ,^.^^ Date RCCCI l# /-a./ SEWER -SANITARY -STORM EA. X)DFT. WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N_ WATER SYSTEM/TREATING 1 shall not employ any person in any manner so as to become subject to the Workers Compensation lifornia. Date PAID NEW RESIDENTIAL PLMB. SQ.FT. Applicant hl I I� NOTICE TO APP�LICANC�R r king t his Certlfkate of Exemption, you should become subject tothe orkscs Compewtionprovivions^fthe Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Date Recei I# TOTAL: VY4CUI IN SEISMIC FEE I hembyaffirmthauhem b a construction lendingagency, for the perform, ..m of the work for whkhthb rmitis Issued (Sec. 3(W, Civ. C.) Lender's Name + f �Ii, Lender. Addmss I cenifythatl have read this ppl tlon..d natethat the above Information is correct lagnmuc, comply with all city and countyordinances and date laws TOTAL: qq��( 16M ELECTRIC FEE PLUMBING FEE dD QTY. MECHANICAL PERMIT FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID: relating to building construction, and hereby authortre representatives of this city to enter a Pon the above-mentioned property for inspection pu rposes. (we) agree to save, Indemnify an d keep harmless the City of Cupertino ago Wt liabi0ties,Judgments, caus a cad expenses which may N any way accrue ALTERORADDTOMECH. Date Receipt# AIR HANDLING UNIT (TO 10,000 CFM) SUBTOTAL: aga Inst said City In consequence of the granting of this permit AIR HANDLING UNIT (OVER 10,000 CIM) CONSTRUCTION TAX Slgnsture of Applicant/Contractor Date D(FDIUST HOOD CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT (TO 100,000 BTU!) Will the applicant or future building occupant store or handle haurdous Date RL of t# material as defined by the Cupertino Municipal Code, Chapter 9.17, and the I IcAth and Safety Codd on 25532(a)? ❑ Yes . r. Will the applicant orpilm, building occupant use equipment or devices HEATING UNIT (OVER 100,000 BTU) TOTAL: VENTILATION PAN (SINGLE RESID) ISSUANCE DATE whichemit hevrdpus ro taminants as defined by the Bay Arca Air Quality Management Ist 7 p BOILER -COMP pI-0a DR 100,000 BTU) -Ycs No have read the hazy materials requirements under Chapter 6.95 of BOILER -COMP (OVER 100,000 BTT1) the Callf.mlallealth fety Code, Sections 25505, 75533 and 75534. I understand that if the uilding does not currently have a tenant, that it is my OCT 7 1991 NEW RESIDENTIAL MECH. SQ.FT responsibility to notify the occupant of the requirements which must W met prior to Issuance of a Certificate of Occupancy. ISSUEDBY: —_ s ' roraulhorl age Data TOTAL: U OFFICE COPY