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24161 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY But1dis,Project Identification - PERMIT Nqn/ Building Address: 2 41 61 06`i0 v arse: r hnnn: - �� A TIE CITY OF CUPERTINO-BUILDING DIVISION 47 APPLICATION / PERMIT O - Architect/ gine;'.. Lie.Na BUILDINGELECTRICAGPLUMBINGMECFIANICAL CATEGORY- CONTROL p - QTY ELECTRICPERMIT FEE BUILDINGPERMIT IN FO Address; - PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby a(firmthat lam licensed 3oftheunder prwlslonse(Chapter9(mmmmc- APPLIANCESPESIDENTIAL JOB DESCRIPTION Ingwit I. fon7000)o(DlWalon3o(the Buslneuand Pm(esslonaC°de,and my �� License is In full(onx and effect. /•2 p G PpNEIS t Lt.nae Cl ss Lie .p HJ /a l Date Contractor rs 1ANTS ARCHITELTSDECLARAT ON O 201-1000 AMPS' caZI understand my plans shaIt be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FC. 0(0 Licensed Profeasl°rul SIGNS ELECTRICAL 1-n'.4 OWNER-BUILDER DECLARATION SPECLILCIRCUIT/MLSC OO�74. I hereby afRrm that I am exempt fromthe Contractors License Law for the 2 following..a.(Section 7031.5,Busineseand Professions Code:Any city or T�(P.ME1II20R EINSf. t' countywhich requiresapermit tOmutmd,alter,lmpmve,de=lll h,orrepair anystmc mpriortoiNB ance,alsomquimstheappliantfmsuchper tt° ..f (� file a signed ammearat that he Is licensed pursuant to the provisions of the POWER DEVICES �Ofn Contractors License Low(Chapter9(commencing with Section 7000)of Divi- SWLhIANGIDOLE- sio"3of the Business and Professions Code)orthat he is exempt therefromand jVALUAIU1ONthe base;for the alleged exemption. Any violation of Section 7011.5 by any iappliant fora permit subjecs the applicant to a civil penalty of not enethanOUTLETSSWITC FI ES five hundred dollars($M. NEWRESIDENTIA EIEC❑1,as owner of the property,or my employees with wages as their sole E CONSTRUCTION compensation,will do the work,and the structure es not Intended or offered forsale(Sec.704,Business and Professions Code:The Contractors License Lawdoes not apply to an owner of property who builds or Improves therms,and _ OCCGROUP .[MITS who does such work himself or through hlsown employees,provided that such Improvements are riot Intended oroffered forsale.If,hcweveo thebullding or TOTAL: Improvementissoldwlthlnoneyearofcomplmion,theowner-bugderwill have t rden of proving that he did net build or improve for purpose ofsals.), QTY, PLUMBING PERMIT FEE FLOOD ZOIJE APN ilk as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE I contractors to construct[he project(Sec.7064,Business and Professions Code: The Contnctor'e Llceran Lw dcea not apply to an owner of property who ALTER-DRAIN&VENT-WATER N-N builds or Improves thereon,and who contracts for such psojecls with a tt(aaor(a)Brensed pursuant to the Contractor's License Law. FEE SUMMARY LJ I am exempt under Seo B&P C for this reason BACK FLAW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N . Owner Dine RECEBPT p ` WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP Off SCHOOL TAX Y_ N_ ❑I hereby affirm that I have a certificate of consent to self-Insure,or 1 RECEIPT N certificate.(Workers Compensation Insurance oracertlfled copy thereof(Sec. GAS EA SYSTEM 3800,LabC / ANCA OUTLETS PARKHE Y_ N_ Policy# Ulf-lY7— RECEIPT Comany GAS-EA.SYSTEM-OVER4(EA)ed. ,BUILDINGDIVISION FEES ❑Certified copy I hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑ Certified copy b filed with the city Inspection division. • CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE - (Thlssectlon need not becomplatedifthe permit lsforouhundret dollar SEWER-SANITARY-STORM EA,200FT. Date Remi t# ($100)otifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N Icertlfy that is the performance ofthewwk(orwNrh this permit Is Issued, — I shall not employ pe n in any manner ao as to _ subleft to the WATER SYSTEM/TREATING Workers Compen ; California.Date O 7d- PAID O Z Applicant Z O NOTICE TO APIIKICANT:II,after makingthls Certlflateof Exemption,you NEZV RESIDENTIAL PLMB. SQ.FT. . Date Recei t# should become subject to the Workers'Compemation provision of the Labor TOTAL: ~ N Code,you at forthwith comply whhsuch provisioramthis pemaltshallbe ILLI j deemed revoked. BU LG FEE CONSTRUCTION LENDING AGENCY a. G I hereby affirm that there is a construction lend Ing agency for the perform- SEISMIC FEE��D D O ante of the work for which this permit is Issued(See.3097,Civ,C,) TOTAL: ELECTRIC FEE 02 Lender's Name PLUMBING-FEE IL H Lendersaddresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE10 O W Icertifythatl have reacithisapplicationand statethattheaboval.far aden 1 mmract.l agree to comply with ail city and countyordinances and state laws . PERMIT ISSUANCE FEES PAID: } W relaringtobuiidingconstmctlon,andherebyauthotl erepruentateve;ofthls - F— Z city to enter upon the above-mentioned property for Impaction Purposes, ALTER OR ADD TO MECH.- (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# agairst liabilities,judgments,cuts and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,100 CPM) SUBTOTAL: aga Imt said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER Iowa cFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and Safely Code Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:' _DD RYea No illtheepplicant° cure building occupant use equipment or devims VENTILATIONPAN(SINCLE RESID) ISSUANCE DATE which emit hazardous air cormnu9anla as defined by the Bay Area Air' - Quality Management District? -- BOILER-COMP OLIjOR 100,00 BTU) 4Vm No havereadthehaza[one.terialsrequirements under Chapter 6,95 of BOILER-COMP(OVER 1(0,000 BTU) the California Health&Safety Code,Sections 25505,25533 and 25534.1 AUG 26 1992 understand that If the building does not currently have a tenant,that it is my' NEW RESIDENTIAL MECH. SQ.PT responsibility to sol Ify the occarpanf of the requirements which most be met Prior to Issuance of a Certificate of Occupancy. - ' - �illY tJl"'vsaYC"f`1_i IIVU Owner oramhodzed agent` Date - ISSUGD BY:�� YY� . TOTAL: OFFICE COPY,