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21795 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Buildln Prved Identification PERMIT NO. 21795 TiuuAddres ding s: as 0 0 e4 IV AE wnere one: APPLI ((O,ITYOFCUPERTINO-BUILDING DIVISION `ate Contrador'e arta: LIc.No: APPLICATION / PERMIT I — 3) BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL Y Architect/Engineer. Lk.Na: J +.S;,J - QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO Address LOU U�r PLUMB MUCH PERMITISSUANCE (�. �j( ❑ ❑ LICENSED CONTRACTOR'S DCC W RATION I hereby affirm that l am licensed under provision.of Chapter9(commenc. APPLIANCESRESIDENTIAL JOB DFSCRBPIION Inensei ;ratan force of Dlvfect. ftheguslnessand[srafeselonaCode,and my .Y�``,'1 license Ie in s fossa and effect. PANELS LicenseC6ss LILY Date Cmdradar ARCHITECTS DECLARATION 201-1000 AMPS q�q�vaOQC I understand my plena shag be used n public records. OVERIODDAMPS SQ.Fr.aFLOOR AREA S/SQ.Fr. ktj Licensed Professional SIGNS ELECTRICAL GG�f kkD0�77 OWNER-BUILDER DECLARATION Spp-CULCIl2CUIT/MIST zp, 4 1herebyaf@m that l am exempt fromthe Contractor'sLimmeLawforthe oo to following reason.(Section 70115,Business and Professions Code:Any city Or O 21., TEMP.MUM OR POLE INST. F� muntywhich requires tomralruct,alter,lmprove,denngah,ormpalr anystmc mpdortolW. a=e aLsorequleestheappBcantforsuehpen tto POWER DEVICES Rte a signed statement that he is licensed pnt kiora uesueto the provof the - Conlractar'.License LawSOCha erg mmmmcin with Section 7000 of Divi- VALUATION S elan 3 ofthe Businessand Profenlora Code)orthatt he is exempt fherefcemand SWEdMINC IDOL ELECTRIC the basis for the alleged exemption. Any violation of Section 7011.5 by any applicant fare permit subjects the applicant to a civil penalty of net room than OUTLGTSSWITCHESFIXTUItroomES 2sS� �q OO� spy fi hundred dollars(S50q. n.owner of f M properly,or my employees with wages ae f heir win SQ.Ff. STORIES TYPECONSTRUCTION W RESIDENTIAL ELECTR mm nstion,will do the wark.and the structure b not intended or offered for nk 7044,Business and Predessiom Code:The ccomect.e.Lim.law $ does not apply to an owner of property who builds or lmpraves l hereon and OCC.CROUP RES.UNITS who doessuch work hlmselforthrwgh his oweemployen,provided that such Improvements are not Intended motioned formic,If,however,the building or - TOTAL: s Improvement is sold within oneyearofe mplellon,the owner-builderwlll have tliLjvrden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONEAPN LI L as Owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to mretrud the project(Sec.7044,Business and Professlma Code: The Contractor's License Law don not apply to an owner Off property,who ALTER-DRAW&VENT-WATER(EA) Wilds or Improves theaccon, and who contrafor such p(o)eche with a c"p.dor(s)licensed pursuant to the COntrador'a License Law. BACK FLOW PROTECT.DEVIGE FEE SUMMARY "I am exempt under Sec B k P C for this reason DRAINS FLOOR ROOF,AREA,COND. . SANITARY Y N Owner Date RECEIPT Y It WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N h ❑I hereby affirm that I have a cerfificam of consent d If-mam,themof ora RECEIPT Y 3800certi,Lab C.Warken CampewHonlmurance era certified mpythemo((Eec. GAS EA.SYSITM-1 INCA OUTLETS PARKFFE Y N polis Isis C.) CgEA.SYSTEM-OVER BUILDING RECEIPT M VER 4(FA) . GAS Y DIVISION FEES ertNed copy is heed with the ed.city GREASE/INDUSIAL WASTE INTERCEPTOR PLANCHECK FEE Certified ropy V filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE gE4yp-R SANITARY-STORM EA 20OFT Date Recei t#Z'lx� (I'hlaaecibn need rad b ENSATI lithe permit V Forane hundred dollars ($100)orless.) WA.fEi(IIFa•1.6e W/VENT/EI-FL,1.R ENERGYFEE Y N I mnifythat In the performance of thework forwhich this Permit is blued, — 1 shall not employ any person N any manner w as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Tawe of Cel forma.Date PAID 0 Z Applicant Date Recei t# Z O NOTICE TO APPLICANT.R,aRer ma king this CerlBlrafe of ExemptlOry you NEW RESIDENTIAL PLMB, SQ.FT. should become subject to the Workers'Compereatm provisions of the Labor TOTAL: N Code,you=at lost hwlth comply with such provislom or this permit shall be BU "/�, lt j deemed revoked. Co CL F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE L St I hercbyafRrmthat there is a construction kndingagency forthe perform TOTAL: ELECTRIC FEE t M zO anceofthework forwhichthis permit liiswed(Sse.3097,C1v.C3 ELECTRIC EEE V Lender'.Name LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W 1certlfythatl have read thlsappliation and Yate that the above Information lemrrect.I agree to complywith all city and county ordinances and Yale laws PERMIT ISSUANCE FEES PAID: C relating to building coratructlnn,and hereby authorize representatives fthis N city to enter upon the abovementioned property for Inspection purposes, ALTER OR ADD TO MECH. ? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Reeei t# V ag.Wt liabilities,judgreantecort...d expenses which may in any wayacxaue AIR HANDLING UNIT ITO I0,0D0 CFM) SUBTOTAL: agaimI n s quermofihegrentingofthlspemnit. / 3/ AIR HANDLING UNIT(OVER tO,OWCFM) CONSTRUCTIONTAX SI tore pliant/Contractor Date EBFIAUST HOOD(W/DUCTE CONSTRUCI70N TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Willt eapplicanl mfuture building occupant store of hand le hazardous F(EATING UNIT(TO 100,000 Date Recei t# materia;as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cc In Section 25532(x)7 HEATING UNIT(OVER 100, TOTAL: I� Yea �No TNllifheapplicantor ture Wileingmeopant use equipment ordevim VENTILATION FAN(gINCLISSUANCE DATE which emit hazardous air mnUmiwnts as defined by the Bay Area Air BOILER-COMP �� • Quality Management DlsfYdt DHP OR IW,gU BTI]) (� 4 Yes r No T y have rcadtM1ehazzr ou.materials rcquircmentsunder Chapter b.95 of R011-GR-COMP(OVER 100,0W BTU) ��� �� the Califem1.Iic.lth A SafetyCode,Sedlona 25505,25533 and 25534, I YQF]T understand that lithe Wilding does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.Fr evV��77 rnponeibility to notify the occupant of the requirements which most be met w prior to issuance of a Certificate of Occupanty. a as Owner or authorized agent Date ISSUED Y TOTAL; OFFICE COPY 1247 >I 0 `Ll i GaYq 9� L • Pv� va�u/ay C O N E,v s /0/%J'o PINrd///r I' //t i P�VghSldin , , e 1��0✓e / /-x wq + wip rDO w a"y,601, '"TIG 2 X F/ JT�c ✓Q ct �„l.riev .. �� � ,Q � 1� •�t � ' � 1, �-'vN ah eh ' • _ A Si------� .. _ (° �-0 -SS Sect-l0 /- a APPROVED It�>L IN ACCORDANCE WITH THE CITY OF © yAN� CUPERTINO CODES AND ORDINANCES $� OATS "IGNED AAT 4ING D JP This set of plans and specifications MUST be kept on the job at all times and it is um DATE__ lawful to make any changes or alterations _ on same without written permission from the building Daot., City of Cupertino. T:y�� The stamping of this plan and specifications SHALL NOT be held to permit or to be an Ipproval of the violation of any provisions It any City Ordinance or State Law. JAN ji 1991 BdDQ61iL INSPECTION OFF CE c • ERi1NA�°-