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23900 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY Building Project Identification - - i PERMIT NO. Bmlamg AaareB.: 2-3900 0 992., ScvE�"rp.4-KS WMrB i /� One: p A .7sZ: 4/0 7 CITY OF CUPERTINO,BUILDING DIVISION cA� Contra or'B—Na'm1e:, Lk.Na APPLICATION / PERMIT - I �312IUR' 8 . BUILDING-ELWTRICAI.PLUMBING-MECHANICAL CATEGORY - CONTROL. Architect/Engineer: Lic.Nee ,. t, ELECTRIC PERMIT )1{4$� �� ,pCEi.t '...BUILDING PERMIT INFO Addrome ITS �rt PEPMIT199UANCE ❑ .❑ LICENSED CONTRACTOR'S DECLARATION I hereby afftrm that l an,lkensud under provisions of Chapter 9(commene. APPLIANCES-RESIDENTIAL ]OB DB bn'1'I01s! inenseISection force of Divfect. ofthe Buelnaaeand Pro(mlonsCode,and my � license la a lull force and effect. PANES License Clam Lic.If Date Contactor UP TO 2DO ANTS - ARCHITECTS DECLARATION. 701-1000 AMPS pp!NO Zp . I understand my plans shall be used as publlcrerords. OVER1000AMPS SQ.FT.FLCORAREA $/SQ.FT. �zz1�j Licensed Professional SIGNS ELECTRICAL G 6 u OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C 71., 5 IherebyatOrmthatlam exemptfromthe Contractor'BLlcense Lwr for - I-.. D oo following reason.(Section 7011.5,Bu.inm and Prodel.r.Code:Any dty or e1 !M /7 �� r P� countywhich requirc.a Permit construct,eller,improve,derellah,orrepair TFMP.METPR ORPOLEINST. aeystructure price to its imseance,also requires the applicant forsuch permit to POWER DEVICES a file a signed statement that he is licensed pursuant to the provisions of the 3µ Contractor's License ILaw(Chapter9(mmmenclng with Section 7000)of Divi. DAT n SWIMMING POOL ELECTRIC SOS the basis for eallegnd Tamption. Any rthat lation b exemp therefrom any UA ON ' O the basis for the alleged exeisthea Any violation of Section no res by any OUTLEISSWITCHFSEXfURES -� applicant for aperm(sub. the applicant too civil penalty of no more than - /ivehundred dollam(5500). NEW RESIDENTIAL ELECT( SQFT. SIOWFS TYPECONSTRUCTION o Q I,as owner of the property,or my employees with wages as their sole compensation,wBl dothe work and thestmcture R not Intended or offered for s 00 .1.(Se.7044,B.at.and Pmfmlom Code:The Contactors License law ' � $ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP - RFS UNITS _ who doessuch work himself orthrough his own employees,provided that such Improvements..net Intended oroftered formic.K howevep thebuliding or TOTAL: Improvementlsaoldwlthinoneyearofcompl&iogtheo ner-builderwillhave ' th�rdenof provingthat he did not build or improve forpurposeofsakJ. QTY,' l,q.,�„IPLUMBINGkIi MIT{' ,Pf ",ruE FLOOD ZONE APN L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE mar-does to construct the project(Sec.7044,Business and Professions;Code: r The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) bunds or imp..tharon, and who mntram for such ploje s,with . ', ',FEE SUMMARY sgDllactor(e)(ceneud pursuant to the Contractor'•Lkenae Law. BACK FLOW PROTECT.DEVICE 1•It ! ' Tj I am exempt under Sec. B &P C for this reason FLES DRAINS FLOOR ROOT,AREA,COND. SANITARY Y N� • Owner Date RFiCEB'TM WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_' ❑i he affirm that I have a certificate of consent to self-Insure,.or a RFAEIPT X certificate of Workers'Compensation Insurance ora certified mpy thenmf(See. 3800,Lab Cd GAS EA.SYSTFM-1INCA OUTLETS PARK FEE Y N _ Policy If - GAS EA.SYSTE -CIVER4(EA) RECEIPT It Co any - BUILDING DIVISION FEES [FC,m7fid mpy 1.herebyfumbhed' GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE Certified copy b filed with the city impection division, CERTIFICATE OF EXEMPTION FROM WORKERS'. CREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANRARY-STORM G.b10Rf. Date. RCCCI [# CTBis section need not be completed if the permit to for onahundred dollars ($100)or tem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N Icertify that in the performance ofthe work forwhich this permit is issued, I shall not employ any Parton In any manner ro u to become subject to the wATERSYsTEm/TREATING workers Cnmpmxatmn Lawsof Ci(fomia. Date ZZ Applicant NEW BESIDENTIALPLMB. SQ.Ff. Date - Recei [# O NOTICE TO APPLICANT-.If,after ma king this Certificate of Exempilon,you Fshould becomd' e..bject to the WorkeCompemat Ion provisions of the Labor TOTAL: 0irCode,you must forthwith merply with such provisions or this permit shall be LU > deemed revoked: BUILDING dCONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirenthat there Is a construction lending agency for the perform ELECTRIC PEE Z ance ofthe work for which this permit is Lswed(Sm.3097,Civ.C.), TOTAL; 00 lender'.Name PLUMBING FEE F Lendee.Addrcss QTY. ;,�_ MECHANICAL•PERMIT' FEE,' LL - - - MECHANICAL FEE O W 1md. that Iagrlhave read thlith allcatynand dcoomyordleanceatethat s eInformation 1 ismtoblding complywo,all ndherb muhoriae lnanmandstatslaws 1 PERMIT ISSUANCE FEES PAID: } relatingoenterupon t ronsove-mn,anddproprtyorizepectionpurpos of this - N 'city to enleruponlhe abovomentloned property for inspection purposes AL77920R ADD TO MECH. ? (We)agree to save,mdemNy an d keep harmless the City of Cupertino - Date Receipt# V against llabllltics,judgments,mks and expenseswitich may In anywayamme AIR HANDLING UNIT 9010,000 CFM) SUBTOTAL: against said t ncensequ ence of the grant ing of this permit AIR F4ANDW NG UNIT(OVER IO,ODO CFM) CONSTRUCTION TAX Q CONSTRUCTION TAX PAID: Signature of�licanl actor Date EXITAUST FLOOD(W/DIIC'D HAZARDOUS MATERIALS DISCLOSURE Will tis ppllcant or future building occupant store or handle hazardous HEATING UNIT CTO 100,000 BTU) Date ReceI t material as defined by the Cupertino Municipal Code,Chapter 9.12,and the I - Health❑ Yand SafetyCode Sectloon25532(z)? 1 HEATINGUMT(OVPRIDg000BTU) TOTAL Will the applicantAure building occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit haanrdom air contaminants..defend by the Bay Area Air Quality Management District? BOILER-COMP GHPOR 100,000 BTU) P ❑Yea ❑No Thavc rcadthehazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVL 100,000 RTU) � ' D the California Health&Safety Code,Sections 25505,25M3 and 25534. I rr.- underetand that if the building does not currently have a tenant,that it l9 my NEWRESIDENTIALMECI'I. SQ.Fr JUN �j5 - responsibility tonotiythe occupantof the requirements which most he met 'IBI KI lag, prior to issuance of a Certificate of Occupancy. Wsw� .Cil r v� c ,Owner or authorized agent Data ice. 1SSUEDBY:W V�K1 OFFICE COPY