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23300 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. l BuBdipg Address: /[-HA f 4 23300. 6 r2 net me: - one. A A A - ti(L CITY OF CUPERTINOBUILDING DIVISION cntotrador'a N' [,k.N°: APPLICATION I PERMIT L_l BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL If Architect/Engineee He.No: QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO Add.. - PERMITISSUANCE ❑ ❑ ❑ K LICENSED CONTRACTORS DECLARATION /�- IhthSechllanti).lamllce3.fthe BuAmvislnnPmfC maCoe,andm-. MPLIANCESRFSTDENTIAL JOB DFSCRB'170N IngwithseMmn7000)ofDiWsl°n3ofthe8usinessand Professions Code,and my license Is in full once cad d(e..n,�A �j PANELS License lass "D Lictl for ✓ H Date Contractor l/ f ARCHITECTS OiCLARATION 201-1000 AMPS 02; I understand retry plans shall be used v public records. OVER1000AMPS SQ. FLOOR AREA S/SQ.FT. G O C Licensed Professional S]CNS ELECTRICAL © f <<N OWNER-BUILDER DECLARATION {"z SI'ECALC]RCUIT/M15C I:-., 1.., I hereby affirenthat I am exempt Contractor's License law for the 0 0-" following reason.(Section 70315,Business and Professions Code:Any city or F ^ l� O G F� TEMP.METER OR POLE INST. �l j U T ER Cci anystmeture pdorto its lssuance,abcounty which requlresa permitrorovtmct,alter,improve,demolLah,orrcpalr o requirestheapplicant for such permitto IVWER DEVICES file a signed statement that he b licensed pursuant to the provislov of the DATE � Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC A770N O slon3of the thignessand I'missel°v Code)orthat he b exempttherefromand ~ P the baste for the alleged exemption. Any violation of Sectio7(B15 by any ' 4 OLrHETSSWITCHESHXFURFS applicant permit subjectstheapplicanttoa dull penalty of not rrorethan $�4 five hundred dollars($500). NEW RESIDENTIAL ELECTR �n ❑I,as owner of the �.FI. STORIES TYPECONSTRUCTION property,or hesemployees with wage as their sole dfor mmpSL,7Kthaotheworkandlhes Code;Thriacture is e Contractors icess,Law O sale(Sec.apply to an ow and Profession who Wilds Contractors License law S$ dons not apply loan owner of property who n lids or Improves thercory and OCC.GROUP RFS.UMTS EE who does mentswork tIntededolf rough his ownemployees, er,theedihatsucr Improvementsarenmintendneyear foomered orsa n,the owevepthderwili have TOTAL: Improvement E sold within mneyear ofcompldioM iheowner-bullderwill have tl�uden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE LI I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN contractors to construct the project(Sec.7014.Busineesand Professions Code: PERMIT ISSUANCE The Contractor's License Iaw does not apply to an owner of property who Wilds or Improves thereon,and who contracts for such p,ject,with a ALTER-DRAW k VENT-WATER(EA) oq➢S.,ador(O licensed pursuant to the Contrad ir's License Law. FEE SUMMARY LJ I am exempt under Sec. B k P C for this reawn BACK FLOW PROTECT.DEVICE Owner Date DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N_ s RECEIPT a WORK MAN COMPENSATION DECLARATION Fp(7�(pg PER TRAP SCHOOL TAX Y_ N_ ❑l hereby affirm that I have a certificate of consent to self-Insure,ora RFCEB'T X mdifimteofWorkers'Compevationlnsunnceoracedifkdcopythemof(Sec' CAS TA.SYSTEM-(INCA OUTLETS PARK FEE Y_ N 3800.lab C.) — Poligtl r1 GAS EA.SYSrCM-OVER4(FA) RECEIPTN Company Amish. - BUILDING DIVISION FEES Certined ropy led w mimed. GREASE./INousrnL WASTE INTFRCErrOR PLANCHECK FEE Certified ropy V pled with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recci HF (rhis section need not be complde t If the permit is for one hundred dollars less.) WATER HEATER W/VENT/FI.ECTR ENERCYFEE Y - N I mdify that ro the performance of the work forwMch this permit is issued. — I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRGTINC Worker'Compensation laws of California.Date PAID O Z Applicant - NEWRESIDENTIALPLMB. SQ.FT. Date Recei t4f Z O NOTICE TO APPLICANT.It,after making this Certificate of Exemption,you should becomeeubjed m the WmI,ena'Compensation provisimu°rhe Labor TOTAL: W Code,you most forthwith comply with such providov or this permit shall W BUILDING FEE W F3 deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE Il 'I herebyaffirmthat there is a cnnetrudicn lending agency for perform ELECTRIC FEE 7Z store of the work for which this permit ex issued(Sec.3097,Cls.Q TOTAL: U O Lenders Nam PLUMBING FEE I- 1.cnaera Aaareea QTY. MECHANICAL PERMIT FEE ' LLhatland - MECHANICAL FEE O U Treaty I agree to comply with readflusapaBcatyndcoutyordinances ndgat saws O W Is rormd.Iagreeto comply wlthallcityand county ordinances and state laws I PERMIT ISSUANCE S,OD PEES PAID: Y a relating tobuilding construction,and herebyauthorizerepresentativeao(this F N city to enter upon the above mentioned propertyfor Inspection purposes. ALTERORADDTOMECH. ? (Weja save,Inde fy an d keep harMess the City of Cupertino Date Receipt# V agabut8t " dgment, sand expense whlchmay inanywayacdue AIR HA NDLING UNIT(TO 10,000 CFM) SUBTOTAL: against Ic e oRhe derating of this permit. AIR I-IANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTION TAX Sigatu `Applicant/ ontra r /7 Date EXHAUST HOOD(W/DUCT) CONS_ TRU ON TAX PAID: HAZARDOUS MATERIALS DISCLOSURE >> .�s _�1—Y1r�Z Will the applicant or future building occupant store or handle hazardous ' HEATING UNIT(TO 100,000 BTU) rS IL _By Date Recei tN material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Hcxhhand Safely Code�Sncdion2S532(s)7 HEATING UNIT(OVER 10B"BTU - TOTAL: -Q F1 Y. LJ No Will theapplicant or future Wilding occupant use equipment ordevices VFNDLATION FAN(SINGLE MID) ISSUANCE DATE which emit hazardous ab contaminants as defined by the Bay Area Al, R� pp Quality Management Di❑stdNo BOILER-COMP P}BrPR 100,000U q BT . V A Q ®. 4havesmail the hazallonsmtea regiremn underChaper6.9io( BOILER-COMP(OVER IW,000 BTU) the California Health h SafetyCode,sections MOS,25833 and 25534. I DEC 15 1992 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FF. responsibility,to cad ify the occupant of the requirements which most be met prior to Issuance of a Certificate of Ocdape racy. . CItT ' v' 1rVj't:nlurV Owner or authorlaed agent Date Op ISSUEDBY: \� C` R7TAL: Y OFFICE COPY