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23986APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Period Identification Building Addm� . S c e - PERVIITNO. . 23986 U%kroa one: y� nq AI f) �1 �J�e 'e„�� „ CITY OF CUPERTIN0.13UILDING DIVISION APPLICATION / PERMIT Contras rsNo a ArMtectIET nmr. Lie Na BULDINC-ELECTRICAIPLbrrINGMEMCEIAMCAL CATEGORY CONTROL N QTY 'ELECT I MFF FEE BUILDINGPERMIT INFO Add.,. PPRMITISSUANC — LICENSED CONTRACTOR'S DECLARATION Ihereby affirm lamBcm3ofthc under kion ChaonaCcerommm APPLIAN DENTIA JOB DESC N os70that ingwith 7000) of Divfect. (the Businmand ProfmloneCode,and my udbo Pro license b in (uR force and erten. Clan Lich enx Corutranor �{ 1T' P fJ/✓ti IV ARCHITECTS DECLARATIONTZ-1014MIN I understand my plane shall be used as public mounds. VER SQ. FF. FLOOR AREA a/SQ. FT. SICK E CA Licensed Professional OWNERBULDER DECLARATION aso I amexempt lrom the orf Liters, Lw lm he SPEC /MLSCI �/R U+VVVV �p ORIOLE INSf. following reason. (Section 7031.5. Business and PrefimAny "Yet countywhich requiresapwane,co requtatter,Improve,densWh, erepair anystructure peartoitatemente thatheeIs also req pursuant to the prow siom of t e floe a signed statement that he (Chapter tlrevtd pursuant to the Pon 7000) of the Contractor's oston.Law ndPrfe9(rom).,that with xemptthcW)of Divi- slun3ofthe 8uelness and Pro(enlov Code)orthat helsexempt lherefromand the basis for the alleged exemption. Any violation of Seaton 7031.5 by any applicant for a permit eabjecbthe applicant to a civil penalty of not morethan IPO DEVICES ' SWIMMING POOL ELECTRIC OUTLEISSWITCHFSFIXTURE4D VALUA710N .(s. NEW RESIDENTIAL ELECTR SQ.FE live hundred dollars ($SM. E] 1, as owner of the property, or my employees with wages as their axle 1 STORIES TYPE CONSTRUCTION compensation, will do the work and the structure Is not Intended or offered for .to fico. 7044, Business and Professions Code: The Contractors License Law _ does not apply to an owner of property who builds or improves thereon, and doessuch work himself earlhrough hlsownemployees, provided thatsuch OCC. GROUT' RES. UNITS Improvements are not Intended oroffered forsale. If, howeec9 thebuilding or L ! Improvement b sold within ovyearofcomplalon,the owner-bu Ilderwill have th,,,);urelenofproving that he did not build or Improve for purpose ofsaoe.). LJ L as owner of the property, am exclusively contracting with Iienxd contractors to construct the project (Sec. 7044, Business and Professions Code: QTY, PLUMBING PERMIT FEE PERI7ISSUANCE FLOOD LONE APN The Coatmaar's License Law doe, out apply to an owner of pmperty who builds or Improves thereon, and who contracts for such projects with a cq ttjaaor(s)Ilcensed pursuant mthe Contractor's Lirenx Law. 1__l I am exempt under Sec B & P C for this reason NALM-DRAIN & VENT - WATER (EA) BACK FfAWPROTECT. DEVICE ' - FEE SUMMARY A=SI DL FEE 5 DRAINS- FLOOR ROOF, AREA, COND. pyY.(UgEct PER TRAP �� SANITARY Y N RECEIPT 0 Owner Date WORKMAN COMPENSATION DECLARATION 01 hereby affirm that I have a eerROate of consent to self- nsure, ora SCHOOLTAX Y_ N_ certlrlateofWorken'Compevatlonlvumnreoracedifiedmpythemof(Sec. 3800,Lab C.) RECEIPT N CAS EA. SYY!'EM-1 INC.40UILEFS PAI21(FEE Y N Policy N RrCEPf N — CF.A. SYSTEM -OVER an ComCertY BUILDING DIV1510 FEE S filed ropy is herebytd. ❑ CertVied copy b filed withh the e city inspection dividon, GREASE/INDU5TRL WASTE INTERCEPTOR - _ PLANCHECK FEE CREASE TRAP CERTIFICATE OF EXM PEION FROM WOR KERS' COMPENSATION INSURANCE (FMssectlonneed not becompleedifthepert tbforovhundmddollan PAID D J SEWER -SANITARY -'STORM EA. 2001717. (S100)rtifyt a I artily that In the performance of the work forwhich this permit Is issued, I shall not employ any person In any manner so as m become subject to the Workeri Compensation Laws of California. Date WATER HEATER W/VENT/ELECTR ENERGY N p WATER S'YST MM/TR[ATING Applicant NOlicant APPLICANT. It, after making this Certificate of Exemption, you should become subject to the Workeri Compensation provisions of the Labor/TOTAL: Cade, you must forthwith comply with such provisions orthb permit shall be deemed revoked. Dale Recei t# NEW RESIDENTIAL PIMB, SQkT. BUIL ING SEISMIC FEE 1 ,CONSTRUCTION LENDING AGENCY Ihereby alOrenthat there is a comtrualon tending agency for the perform anct of the work for which this permit is bored (Sec. 3097, Civ. C.) !r _ ELECTRIC FEE Mender's Name Lender.Addren I-difythatllovemadthbappllatlonandp tethatthe abe heforrution bcorrect. I agree to comply with all city and county ordinanmandetat.law. QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL •'E PERMIT ISSUANCE PEE$PAID: relating tubullding construction, and hereby authorize reprexnlatives o(thla city to enter upon the above-mentioned property for lwpealon purpose. (We) a c to eve, Indemnify an d keep harmless the City of Cupertino ALTER OR ADD TO MECH. Date Receipt# S BTOTAL: against a les,rydgments, oust nd ex enses which may In anywayamme again said ityln m o he ing of this4. permit. ' R.AIRHANDLING AIR HANDLING UNIT CFO 10,000 CPM) UNIT (OVER IO,O30 CFM) CONSTRUCTION AX Stgww of pp lla / on actor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION XPAID: HAZARDOUSMATERIALSDISCL SURE HEATINGUMT(TOI00,000BTU) - Wiiltheapplly of or future building occupant store or ha ed Is hazardous material as defined by the Cupertino Municipal Code, Chapter 9.ij. and the Date R ei HEATING UNIT (OVER 100,000 BTU) _ T Flvlth and Safety Cedt Section 25532(a)7 ❑ Ye No VENTILATION PAN (SINGLE RESID) ISSUANCE DATE P 1 V Willthe applicant orftharebullding occupant uxequlpmet or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management D❑leMa7 BOILER -COMP OHPOR 100,000 BTU) 4 Yes No BORER -COMP (OVER 100,000 BTU) have rc.dth.haza us materials requirements underChapterfi.95 of N the Califemla Health & Safety Code, Sealov 25505,25S33 and 25534. I 19 1992 NEW RESIDENIlAL MECH. - SQ.FI. understand that If the building does not currently have a tenant, that It is my AUG raponsibitity to notify the occupant of the requirements which must he met prior to issuance of a Certificate of Occupancy. IVIS CITY U -`'' _ G ISSUED BY. Owner or authorized agent Date T OFFICE COPY APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Period Identification Building Addm� . S c e - PERVIITNO. . 23986 U%kroa one: y� nq AI f) �1 �J�e 'e„�� „ CITY OF CUPERTIN0.13UILDING DIVISION APPLICATION / PERMIT Contras rsNo a ArMtectIET nmr. Lie Na BULDINC-ELECTRICAIPLbrrINGMEMCEIAMCAL CATEGORY CONTROL N QTY 'ELECT I MFF FEE BUILDINGPERMIT INFO Add.,. PPRMITISSUANC — LICENSED CONTRACTOR'S DECLARATION Ihereby affirm lamBcm3ofthc under kion ChaonaCcerommm APPLIAN DENTIA JOB DESC N os70that ingwith 7000) of Divfect. (the Businmand ProfmloneCode,and my udbo Pro license b in (uR force and erten. Clan Lich enx Corutranor �{ 1T' P fJ/✓ti IV ARCHITECTS DECLARATIONTZ-1014MIN I understand my plane shall be used as public mounds. VER SQ. FF. FLOOR AREA a/SQ. FT. SICK E CA Licensed Professional OWNERBULDER DECLARATION aso I amexempt lrom the orf Liters, Lw lm he SPEC /MLSCI �/R U+VVVV �p ORIOLE INSf. following reason. (Section 7031.5. Business and PrefimAny "Yet countywhich requiresapwane,co requtatter,Improve,densWh, erepair anystructure peartoitatemente thatheeIs also req pursuant to the prow siom of t e floe a signed statement that he (Chapter tlrevtd pursuant to the Pon 7000) of the Contractor's oston.Law ndPrfe9(rom).,that with xemptthcW)of Divi- slun3ofthe 8uelness and Pro(enlov Code)orthat helsexempt lherefromand the basis for the alleged exemption. Any violation of Seaton 7031.5 by any applicant for a permit eabjecbthe applicant to a civil penalty of not morethan IPO DEVICES ' SWIMMING POOL ELECTRIC OUTLEISSWITCHFSFIXTURE4D VALUA710N .(s. NEW RESIDENTIAL ELECTR SQ.FE live hundred dollars ($SM. E] 1, as owner of the property, or my employees with wages as their axle 1 STORIES TYPE CONSTRUCTION compensation, will do the work and the structure Is not Intended or offered for .to fico. 7044, Business and Professions Code: The Contractors License Law _ does not apply to an owner of property who builds or improves thereon, and doessuch work himself earlhrough hlsownemployees, provided thatsuch OCC. GROUT' RES. UNITS Improvements are not Intended oroffered forsale. If, howeec9 thebuilding or L ! Improvement b sold within ovyearofcomplalon,the owner-bu Ilderwill have th,,,);urelenofproving that he did not build or Improve for purpose ofsaoe.). LJ L as owner of the property, am exclusively contracting with Iienxd contractors to construct the project (Sec. 7044, Business and Professions Code: QTY, PLUMBING PERMIT FEE PERI7ISSUANCE FLOOD LONE APN The Coatmaar's License Law doe, out apply to an owner of pmperty who builds or Improves thereon, and who contracts for such projects with a cq ttjaaor(s)Ilcensed pursuant mthe Contractor's Lirenx Law. 1__l I am exempt under Sec B & P C for this reason NALM-DRAIN & VENT - WATER (EA) BACK FfAWPROTECT. DEVICE ' - FEE SUMMARY A=SI DL FEE 5 DRAINS- FLOOR ROOF, AREA, COND. pyY.(UgEct PER TRAP �� SANITARY Y N RECEIPT 0 Owner Date WORKMAN COMPENSATION DECLARATION 01 hereby affirm that I have a eerROate of consent to self- nsure, ora SCHOOLTAX Y_ N_ certlrlateofWorken'Compevatlonlvumnreoracedifiedmpythemof(Sec. 3800,Lab C.) RECEIPT N CAS EA. SYY!'EM-1 INC.40UILEFS PAI21(FEE Y N Policy N RrCEPf N — CF.A. SYSTEM -OVER an ComCertY BUILDING DIV1510 FEE S filed ropy is herebytd. ❑ CertVied copy b filed withh the e city inspection dividon, GREASE/INDU5TRL WASTE INTERCEPTOR - _ PLANCHECK FEE CREASE TRAP CERTIFICATE OF EXM PEION FROM WOR KERS' COMPENSATION INSURANCE (FMssectlonneed not becompleedifthepert tbforovhundmddollan PAID D J SEWER -SANITARY -'STORM EA. 2001717. (S100)rtifyt a I artily that In the performance of the work forwhich this permit Is issued, I shall not employ any person In any manner so as m become subject to the Workeri Compensation Laws of California. Date WATER HEATER W/VENT/ELECTR ENERGY N p WATER S'YST MM/TR[ATING Applicant NOlicant APPLICANT. It, after making this Certificate of Exemption, you should become subject to the Workeri Compensation provisions of the Labor/TOTAL: Cade, you must forthwith comply with such provisions orthb permit shall be deemed revoked. Dale Recei t# NEW RESIDENTIAL PIMB, SQkT. BUIL ING SEISMIC FEE 1 ,CONSTRUCTION LENDING AGENCY Ihereby alOrenthat there is a comtrualon tending agency for the perform anct of the work for which this permit is bored (Sec. 3097, Civ. C.) !r _ ELECTRIC FEE Mender's Name Lender.Addren I-difythatllovemadthbappllatlonandp tethatthe abe heforrution bcorrect. I agree to comply with all city and county ordinanmandetat.law. QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL •'E PERMIT ISSUANCE PEE$PAID: relating tubullding construction, and hereby authorize reprexnlatives o(thla city to enter upon the above-mentioned property for lwpealon purpose. (We) a c to eve, Indemnify an d keep harmless the City of Cupertino ALTER OR ADD TO MECH. Date Receipt# S BTOTAL: against a les,rydgments, oust nd ex enses which may In anywayamme again said ityln m o he ing of this4. permit. ' R.AIRHANDLING AIR HANDLING UNIT CFO 10,000 CPM) UNIT (OVER IO,O30 CFM) CONSTRUCTION AX Stgww of pp lla / on actor Date D(HAUST HOOD(W/DUCT) CONSTRUCTION XPAID: HAZARDOUSMATERIALSDISCL SURE HEATINGUMT(TOI00,000BTU) - Wiiltheapplly of or future building occupant store or ha ed Is hazardous material as defined by the Cupertino Municipal Code, Chapter 9.ij. and the Date R ei HEATING UNIT (OVER 100,000 BTU) _ T Flvlth and Safety Cedt Section 25532(a)7 ❑ Ye No VENTILATION PAN (SINGLE RESID) ISSUANCE DATE P 1 V Willthe applicant orftharebullding occupant uxequlpmet or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management D❑leMa7 BOILER -COMP OHPOR 100,000 BTU) 4 Yes No BORER -COMP (OVER 100,000 BTU) have rc.dth.haza us materials requirements underChapterfi.95 of N the Califemla Health & Safety Code, Sealov 25505,25S33 and 25534. I 19 1992 NEW RESIDENIlAL MECH. - SQ.FI. understand that If the building does not currently have a tenant, that It is my AUG raponsibitity to notify the occupant of the requirements which must he met prior to issuance of a Certificate of Occupancy. IVIS CITY U -`'' _ G ISSUED BY. Owner or authorized agent Date T OFFICE COPY