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22558 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Protect Identification PERMITNO. Building Address: 7 (,5 o�.i✓6D�c Cvobe,,77nle I . 22558 eters %K� /�fLSO� one CITY OF CUPERTINO-BUILDING DIVISION (C�72 �. �AjCo odor N me: ace. o: APPLICATION / PERMIT - J 4�1 /Q��•rlr/s�• 319No� BUIIAINGELECTRICALMUMBINGMECIiAMCAL CATEGORY CONTROL N Arc ted Engin¢r. 41c.Na: C G• BUILDING PERMIT INFO ,Q?Y ELECTRIC,PERMIT 'FEE Address: S4 gC4. -J.3 PQthRTI55IlANCE Pecl LICENSED CONTRACTOR'S DECLARATION El El El I hereby affirm that l am licensed under provisions of Chapter9(mmmenc. APPLIANCES-RESIDENTIAL JOB DFSCRRsITON ingwith 70000of Dlvlelon3o(the Buslnseeand ProfewloneCode,and my limns bin full fo aid dfN PANELS Llmnec C�"/„". CHITECTYIE Date 93ARContnctor YI2DO ANTSOZI understand my place shall be ublic men OVER 1000 AMPS /' SQ.FT.ROOR AREA B/SQ.FT. z�j Licensed Professional SIGNS ELECTRICAL E D ' w . l 6 OWNER-BUILDER DECLARATION SPECIAL CIRCIRT/MISC \ '\Y, R Iherebyaffi mthat[am exempt fromthe Contractors Llcesse awf¢the N.. a.� ZO 7 following reason.(Section 7031.5,Realness and professions Cade:Any city or TEg.1p,METER ORIOLE 1NST. IE ,�'•'ij t"' ro.ntywhlchrequimapermittommtmd,alter,improvcde=o h,orrepalr �� Cal anystmMmprlortolbiswance,alsorequimtheappliantfors.chpermino DAT 9gse3 r u Ole a signed statement that he b licensed pursuant to the provisions of the InWF.R DEVICES w Contractors License law(Chapter 9(cammenclog with Section 7000)of Divi- �- SWPIMING POOL ELCCTRIC sion3o(the Budnessand lsrofesslonsCode)orlhat he lsazempttherc(romand VA 070# ¢ the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE SSSWITCHFSFIXTURES room �� I•aO ..—G applicant fora permit subjects the applicant to a dv11 penalty of not than VV w � five hundred dollars(S500). NEW RGS[DENTIAL ELECTR 71,as owner of the properly,or my employees with wages as their sole --SQFr. STORIES TYPE CONSTRUCTION compereallon,will Bothe work and thestmcture is not Intended or offered for M saIs&c.7064,Business and Professions Code:The Contractors License law t $ docs not apply to a,owner of property who builds or improves thereon,and OCC.CROUP R}UNUS 0.0. who doessuch work himself orthrough his own employees,provided that such Improvements arc not Intended oroffered for sale.If,however,the building or TOTAL: Improvement 0 sold within one yearofcomplMlon,the owner-buRderwlll have .. tt)oburdso of proving that he did not buBd or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN LL�J),as net of the property,am exclusively contracting with 11¢nsM contractors to construct the project(Sm 7044,Business and Professions Code: PERMITLSSUANCE The Contractor's License Law does n¢apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) Wilda or Improves thereon,and who contracts for such Ed (ojes with a cgBt(actor(a)u¢nsed purseand to the Contractor's L1¢nse Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY LI I am exempt under Sm w B k P C for this rean �OUTSJDL RES Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ WORKMAN COMPENSATION DECLARATION HXTURES. RPER TRAP SCHOOL TAX Y N 01 hereby affirm that I haw•¢rtlfl¢te of convent to wl4inure,or RECEIPT N mrtiflate of Workers'Compensatlonlnsunn¢ora¢rtifkd copy<M1ereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N 3800,Lb C.) Pollryp iDy9oia.� - t' - _ GAS EA,SYSTEM-OVER4(EA) RECEIPT CORA a^Y �Yn BUILDDINGGDDII)0 SIGN FRES ❑Certified ropy Ls heed with the GREASE/INDUSTRL WASTE INTERCEPTOR PLAN=D.t, ^ V� �CcrtlOed mpyis(iled with the city lmpedlon division, 4 J CERTIFICATE OF EXEM PT ION FROM WOR KERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWFR-SANITARY-STORM EA.200FT. Reeel [# ITho section need nor be completed i(t W permit b Ionone hundred dollars ($100)orlew) WATER HEATER W/VENT/ELECTR ENERGY F"' N 1¢rllfy that In the performance m .f the work for this permit lsised, — I shall not employ any person In any manner ex as to become subject to the WATER SYSTEM/TREATING . Worker?Compensation Laws of Cal fomb. Date PAID O Z Applicant _Z p NOTICE TO APPLICANT.ft,after ma king this Centlfiate of Exemption,you NEWRESIDENTIALPLMB. SQ.FT. ate Recei lac should become subject to the Workers'Compensation provisions of the Latour TOTAL: I— y Code,you=at forthwith comply with such provisions orthis perrNtshall be j deemed revoked. BL NC •E i' dCONSTRUCTION LENDING AGENCY - SEISMIC F• • I hembyaffirm0et there is a construction lendingagency forthe perform- ELECTRIC ••E n Z ancc.fthc workforwhichthb permit bm bed(Sec.309'/,Civ.C.) TOTAL: 02 Lander'.None � PLUMBI FEE IL I- I<ndcr.Addmw QTY. ' MECHANICAL PERMIT FEE MECHA TEL FEE O Ed Icedifythatl have madthls application and gatethallhe above information (d is correct.I agree tocomply with a6 city and countyonB^ancesand state laws PERMIT ISSUANCE FEES PA D: >. reI.d.g to building commockhm,and herebyauth^rba repreentativea of this Zcity to enter upon the above-mcntlomd property for impection purposes. ALTERORADDTOMECH. (We)agree to save,Indemnify an d keep harmless the City of Cu pen int, Date Receipt# V against liabilities,judgment,costa and ezpenw��vhlch maylnanywayaccrue AIR]CANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against i sequence !t grant Rg fthls permit. AIR HANDU NG UNIT(OVER IO,000CFM) CONST R ON TAX SI a1 rea(Applia^t/Contractor Date hXHAUS"THOOD(W/DUCD CONSTRU ION TAX PAI HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,000 BTU) Date RC # material as defined by the Cupertino Municipal Code,Chapter9.IZ and the Hes Itis and Safety Code Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) T L[ E-1 ye. M No Will theappliant or future bedidbg occupant...equipment mdevices VENTILATION PAN(SINGLE REBID) ,ISSUA EDATE which emit haeardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP D}IPOR 100,000 BTU) PYes Q❑No havem.dtheh. .sma(crisis requiremmeeunder Chapter 6.95of BOILER-COMP(OVER I00,ODOBTU) �s E the Celifemia Health 4c Safety Code,Sections 25505,25533 and 2x534. I Al 9 ID understand that if the Wilding does nor currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFr responsibility to notify the occupant of the requirements which most be mel 1��Y i9 1993 prior to issuance of a Certificate of Occupancy. Owner or authMud agent Date I59U0,dtt U ( TOTAL �W/ ---.���� OFFICE COPY