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22500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY Building Project Identification PELWTNO. .f Builddii/n'g Adddrress / f')f7 Imo'00 d vcg-c9 W�D�ha r t' G G �Vl wnere ams: one: APPLICATM73=1=LATE ey ti CITY OF CUPERTINO-BUILDING DIVISION Contradora a : Lic.No: APPLICATION / PERMIT Z BUILDING-ELFiCnUCAI.PLUMBINGMECI IAMCAL CATEGORY CONTROL# ArcMtect/Engineer. Lie.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Addreu: PFRh9TI55UANCE E] El 1:1LICF.NS ED CONTRACTOR'S DECLARATION Ihereby affirm that Chapter9(mmmmc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION - time.h5ect1on7000)of effeon3o(the Buelnnsand Pro(esslonsC-ods,and my fT Ilan.le In full��a��EB�a�WW c.It, �r �7 /'q PANES f License Clam Lontr .r / w�/ Date Conhactor ARCHITECT'S DECLARATION 201-IODOAMPS pkp�vv nt77 I underamed my plain shallW used as public records. OVER IODO AMPS SQ.Fr.FLOOR AREA $/SQ.FT. !i Fj Licensed Professional SIGNS ELECTRICAL GG'61' OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC 1herebya(flrmthatI am exempt from the Contractor's License law for the Opp following reason.(Section 7WlS, Any city or Business and Professors Code:Atl Z TTMP.MEMDRPOLEINST. countywMch requires ipermit ssuane,also quimseq Emprovedemolhh,ormit Pat,to d� any slmcNrepriorto tatemeltehauanceaice sed pursuant to the forsuconatof to POWER DEVICES C � file a signed statement that he h licensed pursuant to the provhlo�a of the 3µi Courxmrs License l�w(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC �Og swn3 ofthe Business and Professions Code)orthat he is exampttherefromand VALUATION y Sn the bash for the alleged exemption. Any violation of Soctinn 7031.5 by any p65 appllcantfora permlbubjectstheapplcant taacivll pevlty of not moretlun OUTLETSSNSTCHFSFlXTURFS a Ivehundreddolhn($W. NEW RESIDENTIAL ELECIRSQ' STORIES TYPE CONSTRUCTION �n ❑I,as owner of the property,or my employees with wages as their sok ' p compensation,will do the work,and the structure is not Intended or offered for $' q sale(Sec.7044,Business.ed Profeniora Code:The Contractors License Law [�j$$ does not apply to an owner of property who Wilde or lmprovn thereon,and OCC.GROUP RFS.UNITS 0.0. who donsuch work himselforlhrwgh his own employees,provided that such improvements are not Intended oroffered for"Is.If,howeveq the building or TOTAL: Improvement hsold wllhlnoneyearefcompletion,tem owner-W Rderwlll have llig human of proving that he did not WRd or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN F L as owner of the property,am exclusively matncting with licensed' ppT(MITISSUANCE contractors to construct the project(Sec.7054.Business and Professions Code: ((� The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER BA) or improves thereon, and who contracts for such p(ujects with e abador(s)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sm. B A P C for this reason DRAINS FLDOR ROOF,AREA,COND. SANITARY Y N Owner Date RFCER 0 WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y N n 0 hereby affirm a that 1 have a rtNcate of consent to self-Inure, FIXIVRFS or - RECEIPT# mrtlflmteof Workers'Co Nmatlonlnunnamamrtifiedmpythemof&S . GAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y N 38X0,Lab C.) Balky X GAS EA.SYSTEM-OVER 4(EA) RECEIPT# Co��mPPPany BUILDING DIVISION FEES Certified copy Ls herebydwithfurnished.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy le flied with the city Inspection division. CERTIHCAI'V OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thlssection need not becomplded mi lithe pert hSEWER SANITARYforone hundreddollan STORM EA.200FT. Date Recei t# (IllMorless.) WA.I.�HEA.�W/VFNr/LIFGTR ENERGY FEE Y N I certifythat in the performance of thework for which this permit is issued, 'I I shall not employ any parson in any manner so as to becons a to the WATER SYSTEM/TREATING Workers'Compeppdtl��wsof GaiforpIzte_J,.7� � PAID ZZ Applicant //>�-a �, A/ NEW RESIDENTIAL PLMB.__SQ.IT. Date Recei t# O NOTICE TO APPLICANT:[LaRer making this Certificate of Exemption,you Fshould become subject to the Workers''Comperlon provisions ofthe Labor TOTAL: V5 w Code, forthwith comply with such provisions orthh permit&hall be 4 !BUJLDING deemed revoked. LU C CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that h a mrstractlon lending agency for the perform- ELECTRIC FEE Z ance ofthe work for which this permit hhsued fSec.3097,CIv.C.) TOTAL: O O lenders Name PLUMBING FEE x LL f Lenders Address QI'Y. MECHANICAL PERMIT FEE MECHANICAL FEE OU Ieenifythzt l hevereadthisappliation and matethatthe above Information C hcorred.I agree to complywlth all city and county ordinances and mate laws PERMIT ISSUANCE FEES PAID: } relating to building construction,and hereby authorirerepreeentatives ofthis F Z dtyto enterupon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date RCCCI t# (We)agree to save Indemnity an d keep harmless the City of Cupertino P V against llab111lea,j�dgmenta,rxMsand expenses which may In anywayamxue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against old CityEnc sequence oft npanting of this pe I. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX sign uSigof rad r Dat ` EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DIS URB Will the applicant or future building occupant store or handle hawrdous HEATING UNIT ITO 100,000 BTU) material as deft red by the Cu perdso Municipal Code,Chapter 9.12,and the Date Recei t# Ilealth and Safety Code Sec11on25532(a)? HEATING UNIT(OVER 100,OOD BTU) TOTAL' ❑Yes M No L 50 Will the a pplice est orfutu m Wlldingattupan,use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUf��B�TE which emit have rdous air contaminants as defined by the Bay Area Air t./rv� Quality Management District? BOMER.COMPOHPOR100,0I01HU) 4Yn �No JUL 2'6 haveread Heehaw et materials t..25505,2553 andChapter 2S534.I of BORER-COME(OVER 100,000 BTU) 1gPy4' 'T the CaliforniatandtHealth building Code,not currently have a tend,that YtTCS7 understand that rally the not a onfalyhavea tenant,that It met NEW RESIDENTIAL MECH. SQ.FT. nsporoibsua t rally theo ate of ofthe requlrementswhich must be met CHu ast prior to issuance ofaCertlficate of Occupancy. �11II WW Owneror.talimlaed agent Date ISSUED BY: TOTAL: ji OFFICE COPY 1 T - SEWER CONNECTION PERMIT SERIALNO. P " 15157 WUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No..�.J.?d.. Lot No...;�..... G 20065 Stevens Creek Blvd. A.P.N. Bk..-�t1�...... Pg.. ..... Par.(V.:f.... Building C Cupertino, California 95014 Phone(408) 253-7071 Date.-- -4a-4 .... �.................. 19.y�./. The undersigned,being the owner(or owner's agent)of the property located at ... . f 1 •� Zc......................................................................................... consisting of the following TYPE OF BUILDING: Residential: Single family...,..... Multiple............ No. Units............ Commercial............ Industrial............ Other............ No. Units............ does hereby request a permit to connect to the sewer system of the Cupertino Sanitary District. In consideration of the granting of this permit,the undersigned agrees: 1) To comply with all existing regulations and Ordinances of Cupertino Sanitary District and all future regulations and Ordinances which may be adopted. , 2) To maintain the house sewer(that portion of the sewer within private property)and to provide access to the lateral sewer through a cleanout raised to grade at the property line or at the limits of any existing District easement. (Note—Detail J) M 3) To acquire a permit from the ....L l.! �!.....!..r ...«!'•..'-'''e. "!"... .................... Building Depart- ment and obtain inspection and approval by said Building Department prior to covering of the work or use of the sewer. 4) To first expose and inspect for serviceability the lateral sewer prior to starting construction of the house sewer. / Property Owner's Name... (��/ofi?l2... ff7c` �! -�... Telephone..(,_..r� �s2� �s8[o ...................................... Mailing address if different from above.........,...-...:<: ............................................................................................... By-.,.>Q,, f 2... .. . ,.11..:,.r��// ..../........... l`J ❑ A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above property.(Note—See Detail I) FEES: Connection Permit Fee ez, Sewer Service charges to June 30, 19'71.., $.1�........./mo.x.<7 mo. ......`......... Inspection Fee for backflow protection device �O TOTAL $ Z� rzl ',*eceipt of$:1�,........ acknowledged and permit granted. MARK THOMAS&CO. INC., District Manager-Engineer By.....��r'! ... ... e'................... NOTE:See Det ilr on other side of this permit.