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23341 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: yc T- 23341 owner's arae: I Phone: AP --A� BMI A A (-- CITY OF CUPERTINO-BUILDING DIVISION Contractor's N me: L• No: FPLICATION / PERMIT Z a , DING-EI.ECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL# A itect/Engineer. Lic.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PLU' PERMIT ISSUANCE X FV IX LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION with Section 7000)of Division 3 of the Business and PrcfessionsCode,and my license is in full force and effect. PANELS License Class Lie.# Date Contractor ARCHITECTS DECLARATION 201-1000 AMPS 0O Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/cam _ r EJ U Licensed Professional SIGNS ELECTRICAL cW OWNER-BUILDER DECLARATION nSPECIAL CIIRCUIT/MISC t Z I hereby affirm that I am exempt from the Contractor's License Law for the o following reason.(Section 70315,Business and Professions Code:Any city or TLW.D Z T .METER OR POLE INST. county which requires a permit to construct,alter,improve,demolish,or repair �a any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES Ffile a signed statement that he is licensed pursuant to the provisions of the O Contractor's License Law 3 (Chapter 9(commencing with Section 7000)of Divi-' n SWIMMING POOL ELECTRIC � sion 3 of the Business and Professions Code)orthat he is exempt therefrom and VALUATION D the basis for the alleged exemption. Any violation of Section 70315 byy an �� L t 1 OUTLETSSWITCHFSFIXTURFS zs JOti applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). SQ.FT. STORIES TYPE CONSTRUCTION ,r. NEW RESIDENTIAL ELECTR ❑I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for �J, p sale(Sec.7044,Business and Professions Code:The Contractor's License Law rl does not apply to an owner of property who builds or improves thereon,and who does such work himself orthrough hisown employees,provided that such OCC.GROUP RES.UNITS improvements are not intended or offered for sale.If,however,the building or TOTAL: �S improvement is sold within one yearof completion,the owner-builderwid have the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN ❑I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7044,Business and Professions Code: The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) builds or improves thereon, and who contracts for such p{ojects with a FEE SUMMARY contractor(s)licensed pursuant to the Contractors License Law. gpQ�FLOW PROTECT.DEVICE F1 am exempt under Sec B&P C for this reasonOUTSIDE OwnerDate DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_ RECEIPT# WORKMAN COMPENSATION DECLARATION FIXT`URESPER TRAP � _d SQIOOLTAX Y_ N_ vI hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT# certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLET'S tJ PARK FEE Y_ N_ 3800,Lab Q �� Policy# RECEIPT# Co any ) BUILDING DIVISION FEES [Certified copy is hereby furnished. PLANCHECK FEE ❑ Certified copy is filed with the city inspection division. G e/ Jj CERTIFICATE OF EXEMPTION FROM WORKERS' VPAID COMPENSATION INSURANCE !fAffARY-STOZW. F/. Date Recei t# (This section need not be completed if the permit is for one hundred dollars ($100)or less.) � WATER HEATER W/VENT/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 becomes 'ect to the / WATER SYSTEM/TREATING PAID Workers Co???��yy9sation La ra.D ` O Z Applicant ,.�J NEW RESIDENTIAL PLMB. SQ.FI. Date Recei t# Z NOTICE T APPLICANT:Iffaftex0making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE deemed revoked. W � CONSTRUCTION LENDING AGENCY SEISMIC FEE 11*7 a I hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE Z5 1 :3 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) PLUMBING FEE V0 Lenders Name H Lender's Address QTY. MECHANICAL PERMIT FEE LL MECHANICAL FEE 1 certify that I have read this application and state that the above information 171 OW '��.v a is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE t FEES PAID: a. relating to building construction,and hereby authorize representatives of this cityto enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,costsand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL: against said City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 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 9.12,and the EIealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑Yes M No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) b ISSUA�I ATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Mangy tpvnt District? BOILER-COMP(3HP OR 100,000 BTU) I Ye• No i3e rend we nazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) ne California Health&Safety Code,Sections 25505,25533 and 25534. I FEB 2 5 1992 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. j Y >J( i Owner or authorized agent Date01M ISSUED BY:� 4 6 7 �1t TOTAL: OFFICE COPY