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22943
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY Building Project Identification PERMITNO. BuildingAddress: a51 -1119 22943 nere came: ` one: q p p r�–te,. I� �(`�t. CITY OF CUPERTINO-BUILDING DIVISION —7' q Contrator,Name: Lic.No: APPLICATION /PERMIT — ! BUTLDINGELECTMCALPLUMBING-MECHANICAL CATEGORY CONTROL N Architect/Englnrer. Lk.No: \ QTY - ELECTRIC PERMIT FEE - BUILDING PERMIT INFO' Add s PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION �--V I hereby affirm that l am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL JOB DESC ingwith5edion7000)of Dlviston3ofthe Businessand Profession9Code,and my Faf, licenseis in full force and effect. PANEL S LicenseClass LIc.0 N%/" 7 Dale ContractorUP TO RIO ANTS ARCHITECTS DECLARATION 201-1000AMPS qOre 2 I understand my plans shall bo used as public rec.rds OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff. q��++ CO Fd () Licensed Prolesilurul SIGNS ELECTRICAL )�J 2-7♦BQ G�¢' OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC a-IsT ZL, Z I hereby affirm that am exempt fromthe Contractor.License Law for the pp following reason.(Section 7031S,Business and Professions Code:Any city or TEMP.METER OR POLE INST. � cnuntywhich rcquiresa permit tocomtruct,alter,improve,demolish,orrepafr P j anystructure prlorto its issuance,also requirestheapplicant forsuch permit to POWER DEVICES Vfile a signed statement that he is licensed pursuant to the provisions of the 3 w ContnRor.License Law(Chapter 9(commencing with Section 7000)of Ono- In SWIMMNG IDOL ELECTRIC VALUATION O the basis fo the alleged Profmion. Any).dation f Szem therefrom and < thedisc for the alleged exemption. Anyviolationtola civil ofSection70315byany OUTLETS-SWITCHES-FIXTURES [, Os . - 00 appllant for a permit subjects the applicant to a dull penalty of not more than e pp five neired dollars($500). NEW RESIDENTIAL F1 TR SQJ-7. T NSIRUCION as owner.(the property,or my employees with wage as thew sole mmp,nsatfon,wBl doth,work,andthe structure isnot intended or offered for 5 D sa In(Sec.7044,Businessand Professions Code:The Contract.!,License Law 3 2 does not apply to an owner of property who builds or improves thereon,and RO111-RES"TS E who doessuch work himself or through his own employees,provided that such improvements are not intended or offered for sale.If,however,the building or TOTAL: ,0 improvement hisold withinoneyearofcomplebmtheowner-WBderwill have E-111 thi,Ironton ofproving that he did not build or improve for purpose.!sale.): QTy. . PLUMBING PERMIT FEE FLOOD LANE APN IL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(See.7044,Business and Professors code: .Q O The Contractor's License mlaw does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA) Wilds.r Improves there, and who contracts fee such projects with a FEE SUMMARY cqR�(=doKs)licensed pursuant to the C.ntntor's Llcense Law. BACK FLOW PROTECT.DEVICE ` U I am exempt under Sec B k P C (or fhb �/a4 C' j'n.o.nOUTSI DE FEES Owner ex e Date / 1 DRAINS FLOOR ROOF,AREA,COND. SANITARY RFLEB'TN WOR 'COMP SATIONDECILOATI— OSI Tom— �.�S�.RAP - / Q Sp{pOL TAX Y_ N_ ©I hereby affirm that 1 have certificate of consent to self-Insure,or a 6• RECEIPT N certificate of Workere'Comperoation lrsuranreora renifted copy theemf(5ec. GAS EA.SYSTEM-1 INC.40[IILECS PARK FEE Y N / 3800,lab CJ RECEIMM C I'oliryN GAS EA.SYSTQ.1-0VFR4(EA) BUILDING DIVISION FEES omdCray ertified copy is hereby famished. GREASE/INDUSTRL WASTE INTFRCII•TOR - PLANCHECK FEE E3Certdied copy is filed with the city inspection division. aQ CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ^` /f7A COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FC. Date Receipt# (This section need not be completed if the permit is for one hundred dollars ($100)or I..) WATER HEATER W/VENT/ELECTR ENERGY FEEY N' I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any runner so as to become subject to the WATER SYS.IFM/TRFATENG .7,, Workers'Compenaation Laws of Glifornla. Date PAID z Z Applicant NEW RESIDENTIAL PLMB. 'SQFT. Date Recei HF Z 0 NOTICE TO APPLICANT:If,after making this Ceriftnte of Exemption,you should become sub Ft to the Workers'Comperwtion provisions of the Labor TOTAL: Code,you most forthwith comply with such provisions orthis permit shall be BUILDING 'E E W _ deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE s 0. Z Ihereby afflrmthit there la a corstrudion lending agency for the perform- TOTAL: ELECTRIC FEE ,Qd ance of the work for which this permit la Issued(Sec.3097,Civ.C.) f U O lenders Name PLUMBING FEE OD Iender.Address QTy. MECHANICAL PERMIT FEE O W 1 Aifyth.t l have madthbapplicatimand statethat the above Information MECHANICALFEE 1 lacorret.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: relating to Wilding construction,and hereby authorlu representatives of this (— N city to enter upon the above-mentioned property,for impeti.n purposes. ALTERORADD'IOMECH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V against liabilities,judgments,mks and expenses which may in anywayaccme AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL: against said City in consequenm oithe granting of this permit. [1 .y ,may //2& act HANouNG UNIT(OVER lB,000ct�4) CONSTRUCTION TAX signamreot rat/cram LL[J[�f.Ji I We!r —/ EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID: HAZARD %ATERIALS DISCLOSURE Willthe applicant or futurebuilding occupant store orhandle barardous HEATING UNIT(TO 100,000 BTU) Date ReceI t# material as defined by the Cupertino Munidpal Code,Chapter 9.12,and the 1(ealth and Safety Cade Som..25532(a)7 HEATING UNIT(OVER 100,000 BM TOTAL: ❑ Yes 0 No Will the applicant orftture Wilding occupant use equipment or devices VEN'17LATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air p QualityM nagementDi❑❑sot Na BOILER-COMP OLE'OR lEXEEX0 BTU) P A.1 D 4havereadthehazarJoisroterialsmquiremcntsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) the GEfemia l"Iealth k Safety Code.Sections 25505,25533 and 25534.1 NOV -= 7 1991 understand that lithe Wilding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff responsibility to notify the occupant of the requirements which most be met prior to issuance of a Certificate of Occupancy. CITY ur reHiINU Ownermauthorired agent Date ISSUEDBY: JI �-' =y TOTAL: OFFICE COPY