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23892 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-- USE BALL POINT PEN ONLY Building Project Identification 1'F7iMITN2 3 8 9 2 Building Address: K� V`VI 6C `,��1...,,,...hQ� 2� suns s ams: one: T%ra; .o CITY OF CUPERTINO-BUILDING DIVISION Contractors w6 Lie.N. APPLICATION /PERMIT v BUR-DINGELECTRICAI.PLUMBINGMECHAMCAL CATEGORY CONTROL N Arehltea/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter9(curromenc. . APPLIANCES-RESIDENTIALingwltBDFSCRITION Beer.h .full fmce.ed elon3otthe BuelnesswdPro(eselonsCode,and my r ' Q'1—�� tunesbIn lull(once and effect PANELS ' License Cliss Lk.N Dale Contractor —UP TO 2DO AbU ARCHITECTS DECLARATION. 201-10DO AMPS WZZ❑ I understand my plane shall be used as public records, OVERIOODAMPS SQ.FT.FLOOR'AREA s/BQ.Fr. 00 Licensed Professional SIGNSELECTRICAL . OWNER-BUILDER DECLARATION SPEC AL Cl2CUIT/MLSC Z., 7E IherebyafRrmthal l am exempt fromthe Contractor's License Law for the qqqqqq following reason.(Seaton 7041S,Business and Professmus Code:Ancity or P'uf muntywhia mqutmaPer dtlo.n d,alter,imp.v,demolbh,errcpalr TEMP.METER OR POLE INST. 3 aeystructum prior to its lexamnce,aLwrequimtheapplianl forsuch permit to Yd file a signed statement that he le licensed pursuant to the provisions of the (OWER DEVICES Ow Contractor'.License Law lChapter9 ke— cingwhhSection 700(lDivi-�0 slon3ofthe Butl eesand Profenioa Code)orthathebeumptthemfmmand SWIMMING TOOL ELECTRIC VALUA Q the basis for the alleged exemption. Any violation of Section 7011A by any OVTLETSSWITCHESFD(TURES �� applicant fora permit subjenstheappkcant t...vll pemky of rad more than fivendreddolWd.01 pr. '9..' 1 d owner aperty,or my employees with wages as their wk NEWRES[DENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION pa neallllhe pro tion,wo the work and the structure is not intended or offered for O. sole(Sec.7D44 Business and Professions;Code:The Contractors License Law ( $ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS C: whodowsuch work himseRathrough hisown employees,provided that such Improvements are not intended oroHered forsale.If,however,thebuildingor TOTAL: improvement bwldwithinomyearofcomplologtheowner-budderwill have tll,kurden o(proving that he did not build or improve fee purpose ofule3. QTY, PLUMBING PERMIT FEE FICODzoNE APN LJ L as owner of the property,am exclusively contracting with licensed PFRMI.I.L4•UANCE contactor.to construct the project(See 7046,fkabuatnW Professtoru Code: The Camred.e.License Law does not apply to w owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or improves theme,and who contmds for such piy*u with cgllq.dor(.)Icenssd pursuant to the Communes License Law. BACK FLAW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under SmB&P C for this resuresumeanOUTSID17 FEES Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N . Date RECEIT I WORIONAN COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y N ❑I hereby a((Irm ve that I haa artiaau te of connt to wuFIXTURES lhln re,or RECEIPT N 3B00, Lab CJ S of Workers'Compewtlon lruurancemaartlFled copy lheral(Sec. GAEA.SYSTEM-1 INCA OUTLETS PARK FTE Y N ic tLab Policy RECEIGAS EA.SYSTEM-OVER d IRA) DING DIV] fN Com any BUILDING DI VISION FCCS Candled copy k herebyfurnished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑CertlRed mpybflkd with the city Inspection division. , CERTIFICATE OF EXEMPTION FROM WORKERS' ORF-ASETRAP PAID COMPENSATION INSURANCE SEWER-SANRARYSTORM EA 2WBC Date Remi t# Qhsuction need not be completed If the permit is(crone hundred dollars(5100)alcss3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I snotify emplohat fi�y mhe personi performance n tcomearhework to as to hi ems,is subjecit Ist issued, — I shall not empley any person in any manner at u to become ablest to the WATER SYS IM/TREATING Worken'Compenutlon lawaof GR(omia.Date PAID Z Zplicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._5Q,FT. Date Revel t# - should become subject to the Workers''Compenwtion provisions of the Labor TOTAL: �CA Code,you mast forthwith comply with such previsions or this permit shall be LU > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE BUILDING FEE d Ih.mbyafOrmthal there lvacondruction lending agency for the perform- ELECTRIC FEE :3Z ....(the workforwhichthb permit k Wued(5m.3097,Cw.C.) TOTAL: U O Landers Name PLUMBING FEE LL H Lender.Add mu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I nertilylhat l have read this appliationand datethattheabow Information IL ismrrect.I agmto comply with all city and county ordinances datelaw. PERMIT ISSUANCE FEES PAID: } y relating lobulldingconstrudion,and hereby authorize representative.ofthl. ~ city to enter upon the abovo-memioned property for Inspection purposes. ALTER OR ADD TO MECH. Z Z (We)agree to save,indemmly an d kap harmless the City of Cu ped lea, DatC Recei t# - against lisbllitim,judgments,emtsand..per.which may In any wayacere. AIR HANDLING UNIT C17010,ODD CFM) I SUBTOTAL: against old Cltyi.consequen of the an Rngofthlspermit AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX Igmtu of Apphant/ onto ar Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: - HA7A DOUSMATERIALS DISCLOSURE Will the appkant or future building orcupanbtore or handle hazardous HEATING UMT(TO 100000 BTU) Date RCCCI t# r tenalasdefinedbythe Cupertino Murddpal Code,Chapter9.IZandthe I ealth and Safety Codera.�Section 25532(.)7 HEATING UNIT(CAR 100,000 BTU) TOTA n❑ 1W I Yes L_I No Will the ippbam ecu building oaupant use equipment or devices VENTILATION FAN ISINCLE RESID) ISSUANCE DATE which emit hazardous airmntamiwmeas defined by the Bay Area Air Quality Management District? BOILER-COMP OHP OR 100,000 BTU) _ C?hyes ❑No n AID ' ^ ave read the hazar�o..materials requirements underChapler 6.95 of BOILER-COMP'&ER 100,000 BTU) {^ Y the Gllfomla Health&Safety Code,Secttom 25505,255533 and 25534.I understand that if the building does net currently have a tenant,that it 1.my NEW RESIDENTIAL MECH. SQ.FT. ��,�� responsibility to notify the occupant of the requirements which must be mea �� prior to Issuance of a Certificate of Occupancy, Owner or aulha _ Oil r Ur I ized agent ' Date TOTAL: ISSUEDBY: �X' OFFICE COPY 7 .1, s � 333 ^Me-1 a;e;S ,o°uznevp-p fit nmu / suolslnad Rue )o uol;elnre air laaoid.df i ue aq o; ao alwiad of piaq aq 'Aid &Uopeol;loads pue veld sfgl to 2uulwa;s aql 'oul;aadn0 )u A-) ;dan awpmq aq1 WOl) Uolsslwrd ua;pue ;lwq;w mes go suopela;le Jo sOmp he a>lew o; lnpaal �\ un sl J! pue Bawl; pe ;e qof ay; un ;d.34 aq 1snW suogeoploods pur ^:e•d it; ;as s!q! Q3N91S i &OWIL0 ONb43116Ai18300 W 1J10'3N1 1,111 A 30NV0000tl Nf ----=----------- _ OFFICE COPY D JUN-2 5 1992 BLDG. INSPECTION DEPARTMERTi CITY OF CUPERTINO.