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23195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Profen ldenlmeatlon - PERMIT NO. Building Address: . out v�s��s w 23195 n 1 T R.rm: one: - - A CITY OF CU PERTINO-BUI LDING DIVISION Comramtor.N.cm: �n LI_e.No: APPLICATION / PERMIT IleBUILDING-ELECTRICALPLUMBINGMECk1AMCAL CATEGORY CO, 1 a6 ArchltL�/Eng_ineer: Lle O _ `QTY m ' ' t'IELECTRICP'E' EE _ .BUILDING PERMIT INFO Address: 5 F! PERMITISSUANCE 1�� ,❑. .❑ LICENSED CON ACTOR'S 'CLARATION I herebyaffirm that lam Bcansedunder provbl....f Chapter9(mmmenc APPLIANCESIRW611NITIAL - OB DFSCHB'ITON Ingwlth Sedi.n70M)ofDlvl.lon3oftha BuslnenandProfnsi.nsCode,andmy license b In full formand effect PA License Cbn Coma � PP6VI Date Lie.#Contractor 1vU,JY1/ A CHITECI 5 DECLARATION 1'1000 a0Z I nta my pia shall be usedas Ile records - OVLR1 SQ.FT.ILOOR AREA S/EQ.FT. O Fi5License Jami SIGNSELEC L .. < OWNER-BUILDER DECLARATION SPECIAL CHIT/MISC Z t,R7a I hereby affirm that l am exempt(romlhe Contractor'.I icenae Law for the po following mason.(Section 7MIS,Business and Profession.Code:Any city or WKMETER OR POLE INST. countywh eh requires a permit to cors truct,alter,Improve,demolbh,oreepalr anystructure pdorto its issuance,also require.theappllcant forsuch permit to POWER DEVICES rYG file a signed statement that he Is licensed pursuant to the provisions of the Ow Contractors License Law(Chapter9(commencingwithSection70DOofDlvi- 3OI"n SWIMMING FOOL ELECTRIC ��5 slon3ofthe Buslnemand Pm(emlora Code)orthat hebexempt therc(rom VALUATION OQ the basis for the alleged exemption. Any violation of Section 7m LS by any OUTLE'[SSWITCI IESFD URFS applicant fora permit subjects the applicant to a civil penalty of not more than (/ (l five hundred dollars($500). NEW RESIDENTIAL ELECTR 1,as owner of the property,or my employees with wages as their sole e'•Q'FT. STORIES TYPE CONSTRUCTION 7Q compematlon,will d o the work and the structure is not Intended or offered for ❑ sale(Sec 76,14,Business and Pretensions Code:The Contractors License Law $$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS.UNITSwhodonsuchworkhimsxlforthrough hlsownempiW.,provided thatsuch Improvements are not ln(ended orolfered for sale.If how w,r,thebulid Ieg or L: ' Improvement b sold within One year ofcompletion,the owner-bullderwlll have tllc_�uraenof proving that he dm not build or improve for purpose of tale.), QTY, r ,O j'''.PLUMBING PER FEG Lf FLOOD 7DNE APN 1,as owner tr the property,sin exclusively ess.nd ng with licensed PERMIT ISSUANCE TheconColors ct curelmct the project(Sec.apply Business and of property Code: The Coor improves License Lw does not apply tct an owner of property-who ALTER-DRAIN VFM-WA Wild. or Impmvn thereon,and who mntncts for each plojecta with a co,,11VV(Tactor(s)Bcenxd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY Lj I am exempt under Sec B k P C for this reason _ DRAINS FLOORBOOP,AREA,COND. � ' SANITARY Y_ N - Fusser Date RECEIPT p WORKMAN COMPENSATION DF.CIARATION FIXTURES-PER TRAP iOOLTAX Y_ N_ ❑I hereby affirm that I have o certificate of consent d self-insure,them. ora RECEIPT a 3800,Laeo(Worken'Compevau.nlvurance ora certified mpythereof(Sec. GAS.EA.SYSTEM-1 INCAOU7ILETS PARKFEE Y N* Policy Isis CJ Policy Y GAS EA.SYSTEM-OVER 6(EA) RECEIPT p Com any BUILDING DIVISION FEES [Certified copy is hereby furnished.the GREASE/INDUSTRL WASTE INTERCEPT OR PLLANC1U .I4,FEE Certified copy b hereby fM1nis city Inspection division. !/{.eF.`,�L��.///rer///� 00 CERTIFICATEMPE EXEMPTION FROM WORKERS' GREASE TRAP PAID_ �• COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FI, LWe . Recei t# (TM119 sMion need not be completed If the permit b(.mosse hundred dollars (SIM)OHM.) WATER FIEATER W/VENT/ELECT'R ENERGY FEE Y N I mnify that in the performance of the work forwhlch this permit b Issued, — I shall not employ any person in any manner so asto become subjectto the WATER SYSTEM/TREATING 1> Workers'Compensation Laws of California.Date AID OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei tN Z O NODCETO APPLICANT:](,after making this Certificate of Exemption,you Hshould become subject to the Workems'Compensation provtouns ofthe Labor TOTAL: Ln Code,you must forthwith comply with such provbloreorthb permltshall be BUILDING FEE deemed revoked. - CL GCONSTRUCTION LENDING AGENCY SEISMIC FEE _ CL Ihereby affirm that there is a construction lending agency for the perfomv ELECTRIC FEE D Z ante of the work for which this permit Isiswed(Sec.30W,CIv,C) TOTAL: V O Izndert Nana PLUMBING FEE LL Lender.Addmess QTY. MECH_ ANICAL PERMIT FEE :. MECHANICAL FEE O W Indlfythatl have madthis application and statethalthe above Information , O. bco—a.l agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEESPAID: >. W relating to building construction,and hereby authorize representatives of this - H Z city to enter upon the above�menumed property for Wpeetion purposes. ALTER OR ADD TO MECIL Date RCCCI tN _ , (We)agree to save,Indemnify an d keep harrNen the City of Cupertino P against liabilities)adgments,mansard expenses which may In anywayammeAIR HANDLING UNIT(TO 10,MO CFM) • SUBTOTAL: ' against said City In mnsaque ce 5fthe granting.(this pe IL .^ AIR HANDLING UNIT(OVER 10,000C M- ) CONSTRUCTION TAX Applicart/CohEractor V to IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE theappilcznt or future building occupant store or handle hazardous HFATING UNIT(TO 100,000 BTU) Date RCCCj tN material as defined by Ih.Cupertiou Municipal Code,Chapter 9.12,and the - Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU - -_ TOTAL' ❑ Yesr]No Will the applicant or future building occupant use equiperu!nt or devices VEND LATION FAN(SINGLE RFSID) ISSUANCE DATE which emlt brardous air contaminants as defined by the Bay Area Air Quality Management District? - BOILER-COMP(3FIPOR10Q000RTU) 4 Yn rc No s, haffmnia the ealth& Tet materials 2menh5533 aChapter. 1 of BOILER-COMP(OVQ2100,OOD BTU) the Gltandt at lithA Safety Cods,Sections ntly h ve a lma,that I PAID understand that lithe building does not currently have alenanq that ltbmy NEW RESIDENTIAL MECH.• SQ.FT. , prior to issuance sla t.notify the occupant of the mqulrensenta which must be rout ' p�ortOlisuanceofaCertificate o(Ocmpanry. Fa_p .S z+s 1992 `�a` i aV 1 Owner or authorised agent - Date Ieasm�v TOTAL: "(a'jl`I" OFFICE COPY