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24414 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMITN9a 4 4 1 4 wn Building Address: •GJ ao /lJi2lly />�4 . er�ra � GA 97 5 v era scot: APPLICA LION SUBMII FALA � as jgp$ CITY OF CUPERTINO-BUILDING DIVISION p Z as :.Nam: (1� Lic.No: APPLICATION /PERMIT Lo VCATEGORY V�Y' chi Y . V t 1 BLTLDINGELECTRICALPLUMBINGMF LAICAL CONTROL Y Architect/Engineer. Lle No: QTY_ ELECTRIC PERMIT:" FEE' ' BUILDING PERMIT�.INFO,_.i°.I;; Address: PERMITISSUANCE 7T ❑ ❑ ❑ LICENSED at Ia CONTRACTOR'S DECLARATION Tl Ihercbyion 70 thatlam Bcenxd under prov..nd of Chapter d( ,..mc- APPI-IANCESRESIDENfIAL JOB DESCRII'fiON ingwhh Settlors force of Dlvblon 3 ofthe Buslnessand ProfemlonaCode,and my license la in full force and effect..NPANELS I \,� 46W C KO License Class Lie.Y Wr( 1 s- Date —trn�?nelAkflOc ( C ARCHITCHIT ECTS DECLARATION o0 AMPS Q7 Iundentand my plan ahaBbe used apubb « ccrnOVER ds. OVER 1000 AM['S SQ.FT.FLOOR AREA 5/SQ.Fix CSIGNS ELECTRICAL as\ta ^ ® I w'\`., , x fi U LicensedProfeviovl / Irr—� �G OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C / p�7 Ihembyaffirmthatlamexemptfromthe Contractor's License Lawforthe a ?Z fo0owing reason.(Section7m15,Businessand Prefessiov Code:Mydtyor TEMP.METE2OR POLE INST. r l � �J ' {� R Fp' countywhkhrequi apert ttommtma,Oter,impmv,de=lbh,orrepair 7 3'a te anystmu mpnortoltsL ame,aborequtr stheappH.ntforsuchpermitto POWER DEVICES 23 c. file a signed statement that he b heomod pursuant to the provisions of the S00 ConractoI License law(Chapter9(commencing with Section 7000)of Divi- SWINtMING POOL ELECTRIC VALUAIIO 0a sion3o(the Buslnevand Pmf lora Code)orthathebeumptthemfmmand a S^J the baso for the alleged exemption. Any violation of Section 70715 by any OU`LE.IS,SW TCHE&FlXTURESPt a `Pta pp0ont fora permit subjects the applicant too avil penalty of not more than I/ dred dollen(5500). NEW RESIDENTIAL ELECTR SQ}T. STORIES TYPE CONSCAUCTION a owner of the property,or my employees with wage as their xle CZa pensation,willdothe werk,and the structureb net intended or offered for 5 ❑ le(Sec 70K Bualxv and Protrusions Code:The Contractor's License Law �$ does not apply to an owner of property,who build.or Improves therron,and OCC.GROUI' RES UNITS r-'^ whodoessuch workhimaelforthrough hiaawnemployees,provided that such Improvemennare not Intended oroffered for sale.If,however the building or TOTAL Improvement bsold withinoneyearafcompletion,eheawner-builderwill have - th as own! of proving that M did nus build or Improve for purpose ofxk.). QTY.. .PLUMBING PERMIT' FEE'c FLOOD WNTE MN 1, ner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec 7014,Business and Professions Code: the Contractor's License Law does not apply to an owner of property who ALIFR-DRAW&VFM-WATER(EN build.or Ire roves thereon,and who contnaa for suchwith a - - mut�- r(s)licensed pursuant to the Contractor's License Law. BACK FLOW ILROTECT.DEVICE '" "r- FEE.SUMMARY•r va, ')? sea LJ I am oemp under Sec • B &P C (or the reasonOUTSIDEFEES 1rJ--/Q�, DRAINSFLOOR ROOF,AREA,COND. SANITARY Y_ N_ Ow — — RECEIPT Y WO 01f f Oh FN'�ATION DECLARA ION pIXNRFS PER TRAP SCHOOL TAX Y_ N_ ❑1 hereby a irm tha I have a cerH(late of consent to xB-Inure,ora RECEB'r Y certi0ot<ofWorken CompensatlonlnsuranceoracertRkd mpythercof6ec. GAS EA S-YS-I'EN-11NCA OUTLETS PARK FEE Y N_ 3800,L b C.) RECEIPT Y Policy Y GAS E.A.SYSTEM-OVER 4(EAI Com any BUILDING DI VISION FEES Cetllfled copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Certiie l copy Is filed with the city inspection division. CERTIFICATE OF O(EMPHON FROM WORK ERS' GREASETRAP PAID COMPENSATION INSURANCE SEWFR-SANITARY-STORM EA.2(IOF. Dale Recel t# (Thissection need not be completed B the permit is Toro ehundred dollars (SI00)erlrm.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ I certify,that In the performance of the work forwhich this permit Is blued, I shall not employ any person In any runner so as to becorte subject to the WATER SYSTEM/TREATING PAID Workers'Compensation Laws of California.Date — 0 Z Applicant NEW RESIDENTIAL PLMB. e.QFT. Date Recel t# Z NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you should become subject to the Workers'Compensation provbkns of the Labor TOTAL: � N Cade,you at forthwith comply with such provisions or this permitshallbe BUILDING FEE W > m deeed rH evoked. SEISMIC FEE CONSTRUCONLENDING AGENCY CL M C Ihercby work for w them baconsemttssued lend Oing agency for the pedorm TOTAL: ELECTRIC FEE 0 Z Lendof er's Nwork(arwhkh this permit blssued(Sec 3097,CI¢C') - PLUMBING FEE IL l- Lendefa Name )- lenaera Aaareaa QiY. �`. MECHANICAL PER T. - MECHANICAL FEE OW Iout ify that l have read thisappBmtion and state that the above Information 1 bcorrea.Iagree tocomply with all cry and county ordinances and state laws PERMITISSUANCE F€ S-t�T70�7 } relating to building conatmetlan,and hereby authorize representatives of this r C r U) city to enter upon the above,mentloned property fns lnspectlon Fiepmes. ALTERORADDTOMECH. Date ReCeipt# (We)agree to save,Indemnify and keep harmlea the City of Cupertino AIR FVsNDENC I1M1Tf(TO 10,000 CFM)(..� agaiut WbiBtln,judgments,cortaand expenses which may in any wayacave SUBTOTAL: .gmnst said C' consequan of grsatin of thio permit. CONSTRUCTION TAX / AIR HANDLING UNTT(OVER IO,WOCFM) Sig.. P rant ant r D,te EXHAUST HOOD(W/DUC'n CONSTRUCTION TAX PAID: H RDOUS MATERIALS DISCLOSURE Wllltheapp m orfuwmbulidingoceapantsmreorhandlehazardam HEATING UMT(TO 100,000 BTU) _ Date RCCeI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER IW,"BTU) TOTAL: 0Yn n VENHLATION EAN(SINGLE MID) ISSUANCE DATE WIII the appllnnt or future building occupant use equipment or devices which crut havrdous air contamba nta as defined by the Bay Are.Air Qoality Management Ditadet? BOILER-COMP OHPOR 100,000 BTU) 4Yn ❑No A' ; �� havercadthe havrduusnutenabrcqulmments 'e"ChapterG93of BOR.ERCOMP(OVEt100,000BTU) the Callfomla Health&Safety Code,Sections 25505,75533 and L4M. IyY RESiDEMIAL MECFL SQ.IT. understand that if the building does not currently have a tenanp Ihat it b my V(l 7y rnporcubility,to notify the occupant of the mquirements which must be met t © 1992 prior to Issuance of a Ceniflate of Occupancy. s• Owner.,authorized agent Dae ISSUED TOTAL: OFFICE COPY