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22171 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project IdentificationPEILMII'NO. Building Address: S _ �F� . 94), 22171 e s onto: ` one: TQ j '2 I/4E- CITY OF CUPERTINO-BUILDINGDIVISION L� 1 L 1J Cantactar.Name: Lie.No: APPLICATION / PERMIT .7 / J I Architect/Engineer. Lie.No: tD BUILDINGELECTRICALPLUMBINGMECHANI AL CATEGORY" CONTROL�;'© QTY ELECTRIC PERM FEE BUILDING PERMIT INFO Address: PERMITISSUANCE � Y . k4 (� LICF.NSF.D CONTRACTOR'S DECLARATION thereby affirm that l am lensed under provielons o(Chapter9(mmmenc. APPLIANCES ENDAL ^ — lOe RB'pON ingwlth Scdion7000)of DlvEdon3ofthe BusWasaand ProfessloesCode,and my ` K / Iipense Isesla full force and died. PANELS LicenClass Lic.B Date Contactor ARCHITECTS DECLARATION AM 09Z I understand my plans shall be used upubllc records. ERI"AVVS rSQ.FT. FLOOR ARREA I� 'S� gyp! O SIGNSE EC L gkyyx�—ti..4 —L O L/ E1 Licensed Pmfeaslonal (� G OWNER-BUILDER DECLARATION U C MISC / '^T) r / 8 Fo, Iherebyaf0rmlhat lamexempt(romthe Contactors License lawforlhe VTIW' O �� qqq�q following reason.(Setion 7MI.5,Bwlnessand Professions Code:Anyetyor ,MEIEROR NST. ¢�+ 25 a�Q F� countywhich requima permit toronttrucr alter,Improve,demolish,creepair J I�. f �L anystmctum prlorto its issuance,alaorequires theapplicant(orsuch permit POWER D ,S .� q file a signed statement that he is limesed pursuant 1p the provident of t D� 3 w� Contactors License Law(Chapter9(rommenWg with Sect10n 7000)of Divl- N-c-1 FlEC1RIC don3 ofthelusined and Profeaslmis Code)orthat he la exempt thereftemand 6 the basis farthe alleged exemption. Any violation of Section 7m1.5 by any OUTLETSSWITCHESFIXTURES 5� applicant fora permit subje tithe applicant to a civil penalty of no more than �` a ndreddpllora%[O, NEW RESIDENTIAL ELECTR_SQd7. STORIES TYPE CONSTRUCTION ... owner of the property,or my employees with wages as th sole c ve pentalion,wllldothework,andthestmaureisna intended or Bred for O (Sec.7049,Business and Professions Code:The Contactors cove Law $ does not apply to an owner of property who builds or improvss thereon,and ' ^ who doesauchwork hlmselforthrough hlsownemployces,provided that such --SIR OCC.GROUI' RES.UNITS improvements arc not Intended proffered formic.If,however thebuilding or improvement lasoldwlthln oncyearofcompletion,the owner-builderwill have tlic.trurden of proving that he did not build or improve for purpose of sale.). QTy; PLUMBINGPERMIT FEE el-DODzDNE APN u L as owner of the property,am exclusively mnlracting with licensed PERMIT ISSUANCE contactors to rovtruct the project(Sec.7094,Business and Profeniov Code: The Contractor's License law does not apply to an owner of property who ALTER DRAIN k VENT WATER(EA)builds or Improve thereon,and who contracts for such Injects with a a1 cgBt�+slur(.)Bcenaed pursuant to the Contactors License Law. BACKFfAW PROTECT.DEVICE FEE SUMMARY' LJ 1 am exempt under Sec. B k P C for this reason Owner ate DRAINS R ROOF,FLOG A SANITARY Y_ N_ DAREA, RECEIVE WOR"ANmthat COMPENSATION DECLARATION FD(TURES-PER TRAP SCHOOL TAX Y N []I hereby affirm that I have a Imnarate Of consent to apythemo ora RECEIPT.If cM0e LxtbeC'Workers'CompevatlOn lnsurenm Oraani(led mpythereof(Sec. EA SYSTEM-1 INCA OUTLETS r PARK FPS Y_ N Policy M pe RUIZ=X Com any S BUI LDING DIVISION FEE Certified copy is herebyfamished.thehM. R U I EPTOR PLANC14ECK FEE Certified copy la filed with the city intpectlpn division. l/e2J CERTIFICATE OF EXEMPTION FROM WOR K ERS' GT0ASdYkAPU1 16W PAI _ '~ COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200PT. D to ecei tN �5t (This taction need no be completed Bthe permit Is forov hundred dollars ISI00)orless.) WATER HFATeftwrvpxr/ELECTR ENERGY FEE Y N I certify that In the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject 10 the WATER SYSTEM/TREATING Workers'Compenmtionlaws of California. Date PAID Z ZNOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FC. Date - Recei t# O should becomeaubject to the Workers'Compensation provisions ofthe Labor s TOTA N Code,you must forthwith comply withsuch provisions mthla permit shall be BUILDING a Q W > deemed revoked. d CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there Is a construction lending agency for the perform- ELECTRIC FEE Z ance of the work for which this permit ot Lvucd(See.3097,Civ.C.) u O ]ander.Name - PLUMBING FEE LL f Indere Address QTY. MECHANICAL�PERMIT' FEE MECHANICAL FEE O W Icertifythatl have read this application and nate that the above loforrtatlon 1 Is correct.Iagree to cpmplywllh ell cityand rountyordinanm.and state laws PERMTTISSUANCE t S �� FEESS�/ ��A >. N relating to building rovtruction,and hereby authorize reprexntalivn of this Z citywerecrupon the above-mentioned property for Wpectlon purposes. ALTFRORADDTOMECH. Date Recei tN _ (We)agree to same,indemnify an d keep harmless the City of Cupertino P garat liabilities,judgments,"sand expenses which may in anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: ` I�jl�d�City ,/I,n mvary_na of t/ fanting of lila pertnlL AIR HANDLING UNIT(OVER 10,OW CIM) CONSTRUCTION TAX 'a7C"���p� •' �2 CONSTRUCTION TAX PAID: S mrc f pplirant/Contaci Date IXHAUS'C HOOD(W/DUCT) HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfuture building occupantvoreor handle hazardous HEATING UNIT(TO 100,000 BTU) Q material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recd Health and SafetyCode Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) MYes No Will the applicant or tore building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit haardom air mntaMoants as defined by the Bay Area Air Quality Management District? BOILER-COMP(3HP Oft 1()0,0(q BTU) Yes No havareadthchazaMous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) D the California I lealth k Safety Code,Sections 25505,25513 and 75539,I A ' understeM that if the building does not currently have a tenant that it is my NEW RESIDENTIAL MECH. SQ.FT responsibilityortunc moa Catioccte of Occupa requirements which must be met JUN 24 1992 oauance ofty the occupant QF Owner or authorized agent' Date 11 IYSSROBY! `�"•� F� I OFFICE COPY