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23433 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'en Identification Build org Address � L. -, Lt � (.PIRA�w��t. p�, �v�� ,,4io O(+ . 950 l PHRVflT NO. 23433 caner one:p Gh l,G AAE CITY Or CUPERTINO- BUILDING DIVISION APPLICATION / PERMIT BUILDINGELECTRICALPLUMBINGMECHAMCAL 1 'Z ^ T—" ContranoraNama CC / ri' Liz. No: I-1 A l l p H i/U�jtL ( CATEGORY CONTROL p Architect/Englneer. Lie No: QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO �/r // Address:I � � � yJ `' ❑ 1:1 El�. PERMIT ISSUANCE LICENSED CONTRACTOR'S DEC RATION I hereby affirm that l am licensed under provisions of Chapter9(commene- Ingwith Section 7000).!Divlslon3 oRhe Bodnessand Profeselom Code, and my Rance is In full force and offset. se Lia^CleLION Date Cmmmc.r ARCHITECTS DECLARATION I understand my plans shall be used as public records. Licensed Pmfenimal OWNER -BUILDER DECLARATION Iherebyaf.thatlamm exemptfrotheContractor'sLianselawfeethe following reason. (Section 70315, Businemand Pmfesslons Code: Any city or cwnlywhich requires a parr i t to construct, alter, improve, demnRsh,orrepair anystmcture prior to its lssuanee,also requlreathe applicant for such permit to file a signed statement that he b licensed pursuant to the provisions of the Contractors License Law (Chapter 9(commencing with Section 7000) of Divi. sion3 of the Business and Profemlom Code) orthat he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit sub)uouthe applicant to a civil penalty of not more than five hundred dollars($SM. 1-11, as owner of the property, or my employees with wages as their sole compensation, will do the week and the structure Is not Intended or offered for sale (Sec 7046, Business and Profes fleas Code: The Contractors Liame Law does not apply to an owner of property who builds or Improves thereon, and who doeseuchwork himself or through hlsown employees, provided that such Improverrants are not Intended or offered for sale. If, however, the building or Improvement h sold within oneyearofcompletion, the owner -builder will have ^ of proving that he did not bund or improve for purpose of sale.). s owner of the property, am exclusively contracting with licensed tractors to construct the project (Sec. 7064, Business and Profenloos Code: Contractor's License Law dm not apply to an owner of property who lids or Improves thereon, and who contain for such ptojecie with a Aactor(s)IIce^sed pursuant to the Contractors Llmme Law. LJ I am exempt under Sec. B k P C for this reason --' '- -' APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS) LM IQ 200 ANTS — 201-1000AMPS OVER 1000 AMT'S SQ. Fr. FLOOR AREA ' I P Y T E R L A Z ^r' f/SQ. Fr. SIGNS ELECTRICAL SPECIALCItCU1T/MISC �.jtp M= OR POLE ]NST. -11M POWER DEVICES DATE SWIMMING POOL ELECTRIC OUTLETS-SWITCHESFIXTURES VALUATE NEW RESIDENTIAL ELECTR FT. 5TORIES TYPE CONSTRUCTION TOTAL: . QTY. PLUMBING PERMIT FEE OCC. CROUP RFS. UNITS PERMITISSIIANCE ALTER -DRAW kVENT- WATER (EA) FLOOD TONE APN BACK FLOW PROTECT. DEVICE FEE SUMMARY DRAINS FLOOR. ROOF, ARCA, GOND. FD(TURES PER ,TRAP SANITARY Y N_ RECEI T If Owner Date WORKMAN COMPENSAiIONDECLARATION ❑I hereby affirm that I have a certlRate of consent to opyth err ora 3800,abofWorken'Compevatlrnlvurance oracerl(led ropy therrof(Sec. 3800,LabC.I Policy X SC1100L TAX Y N_ RECEIPT X GAS EA. SYSTEM -1 INCA OUTLETS PARK FEE Y N PT X C. nY GAS EA. SYSTEM -OVER 4 (EA) DING Of BUILDING DI VISION FEES ❑ certified copy Is hereby fumished. ❑Certified ropy Is filed with the city Inspection division. sGREASE CERTIFICATE OF EXEM PTION FROM WORK ERS' COMPENSATION INSURANCE (Ihlssection need not M completed If the pemdt V fee ors hundred dollar (s100)eefy that Ianotemployanypemniaof the nnerwmtowork ohtNsp.b is lamed, I shall not employ any person en any manner so a to become eubject to the Workers' C"mpensatlon laws of California,oCalifornia, Date Applicant NOTICEco APPLICANT: If, aftermaking Exemption, you pe atim Certificate Of should become forth to the ply wit Comprovison orthloruofthe Lab or Code, you must forthwith comply with such proal ion+orthh permit shall be me dred revoked. CONSTRUCTION LENDING AGENCY Iherebyaflrm that thea is a construction lending agency for the perform, ance of the work for which this permit Is issued (Sec. 3097, Civ, CJ Lender'. Name Lender'. Address I artifythatI have read this appliatlon and statethattheabove Informative 9 correct.I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of thio city to enteruprn the above-mertimed property fee Inspection purposes. e) agree to save, Indemnify an d keep harmleas the City of Cupertino ;agai Rabilln,judgmenle, sand expenseswhlch maylnan wayaccrue a said Cityinc en ofthegr%n gofthl.pAIRHANDLING gmmreof Applin Contract nate HA DOUS TF.RI DISCLO RE Will the applicant turcb Ing Mature or ndle hassnlous materlalasde0oedb the Cupertino MunicipalCode, Cha Chapter 9.1 y pept 2, and the Healthas Safety Cade Sectl"n 75532(a)7 - r-1 Yes r] No Willcoact applicant orr tura contaminants ant by equipmthe Bay Area devices which emit hazardous airrict? ant. as defined by the Bay Arca Air Quality Management District? 'PhYea rd No ave read the I. ore materials requircmants underChapler6.95of the Glifemla Health k Safety Code, Smto. 255°5, 25533 and 2.5534. I and crsta^d that if the building don not currently have a tenant, that It is my respomib°ity to notify the occupant of the requirements which most be rtstR prior to issuance of a Certificate of Occups ney. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE PAID ' Date ReeeI t# TRAP SEWER -SANITARY -STORM EA. 20017. WATER HEATER W/VENT/ELECTR ENERGY FEE Y N PAID Date Recel t# WATER SYSTEM/TRRATIN'G NEW RESIDENTIAL PLMB. SQ.P'r. TOTAL: BUIL12ING FEE TOTAL SEISMIC FEE ELECTRIC FEE PTY. MECHANICAL PERMIT - FEE'' PLUMBING FEE I PERMIT ISSUANCE ` ALTERORADDTOMECH. MEC]-IANICAL FEE FEE$FAID: Date Receipt# AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL' UNIT(OVER 10,000CIM) CONSTRUCTION TAX EXHAUST xoDD Dv/OUCH - CONSTRUCTION TAX PAID: HEATING UMTGO 100,"BTU) Date Recei t# HEATING UNIT IW,000 RTU) TOTA VENTILATION FAN (SINGLE RFSID) R Ipq$Iy'ApNq CE DATE ' Y± I\ A Y MAR 23 1992 Irl' I. UI" V COPL�LII1414 / ISSl1ED UY`�`/ BOILER -COMP O}E' OR IfN1,0(D BTU) BOILER COMP (OVER 100,000 BTU) NEW RESIDENTIAL MECFL FT Owner or authorized agent Data - OFFICE COPY