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23500 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMITNO. c a Buildin`Address: 23500 _225 1 fOP19Y 17 P G v �,�7/N O C �Q/V y Wo/y(?96j{' / '-UW CITY OF CUPERTIN0.BUILDINC DIVISION AFFL ceatractor'.Name.. Lie.N. APPLICATION /PERMIT Architect/Englnrer. Llc.No: BUILDINC—aFCTMCAI PLUMBING-MECHAMCAL CA RY CONTROL N QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address ��x-/ PERMITISSUANCE ❑ ❑ 11LLICENSED CONTRACTOR'S DECLARATION % I hereby afftrmthat lam licensed under provoionaof Chapter 9(co.c APPLIANCES RESIDENTIAL JOB DESCRIPTION Ingwlth Section 7000)of Di i,ion3ofthe Businessand Profeslona Code,and my liansc ie In fug fora and effect. PANELS 2 licenseClam L1r.N Date Contactor ARCHITECTS DECLARATION 201iftP '\ S raz Iunderstand my plans shag be used as public records, OVERI030 SQ.IT.FLOOR AREA $/SQ.FT. O o Licensed Professional SIGNSELUC - �< OWNER-BUILDER DECLARATION SPECALCI2CUIT zp, a Thereby afflnnlOWNE exempt ER DE LARATIO License law for the oo (olbwing reason.(Section 7011.5,Business and Profeeslone Code:An ci or TRr1P.M ORIPOI.E IN county nystmomr rtoiapermit to aeaLnstruct,reui atheaplimntfmollch,arretto ggg any awcturc statement that he 6lkw rsed pursuant t the provisions of it a POWER DEVICES o floe a signed mcame,Lt that he t r 9(mm pursuant it the pro7000) of the Contractors ushae Law(Clupler9(mmmendng with Section 7000)of Divi. VALUATION SOS /'0 buelncssand Pro emions Cade)orthat he se limp there(romand SWIMMING POOL ELECTRO �D tr the alleged exemption. Any violation of Section 7031.5 by any O ara permit eubjeciatheapplicanlloa dull penalty of not morelhan OUTLETSSWITCIiGSE1XTURFS d dollars BS(XE, NEW RESIDENTIAL ELECTR SQ.FT. SIO TYPE CONSTRUCTION wner of the property,or my employees with wages as their sole murpensaeon,wgl dothe work and thestructure,b not Intended or offend for O ale(Sec.704 6,Business and Professimu Code:The Contranm's License Law does not apply to an owner of property who builds or Improves Ihereary and OCC.GROIIP RFS.UNITS who does such work himself orthrough his own employees,provided that such Improvements are not Intended moffered for sale.I(however,thebulldingor TOTAL: Improvement bsold within mayearofmarplallon,theowner-builderwill have tf *rden of proving that he did not build or improve for purpose ofule.), QTY. PLUMBING PERMIT FEEFTgp ZONNE APN u I,as owner of the property,am exclusively contracting with licensed contractors to mrutruct the project(See.7006,Buslnessand Profenbre Code: PFRMITISSUANCE The Contractor.License law don not apply to an owner of property who builds or Improve thereon,and who contracts for such p\oiects with a ALTER-DRAIN&VENT-WATERBIA) cgp((acror(s)licensed pursuant to the Contractor.License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY U I am exempt under Sec. B &P C for this reasonQIJTqinr DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N net Date RECEIPT N RIM MPENSATION OECLARA O FIXTURES PER TRAIT SCHOOLTAX Y N hereby affirm at I have a certificate of consent to self-Insure,or REC®'T N certificate of Workers'Compensation Insurance ora certified copy thimef(gec. 3800,lab C.) GAS EA,SY517T7-1INCA OUTLETS PARK FEE Y N ECE Policy Y GAS EA.SYSTEM-OVER 4(EA) DING DI'N Co����mppppany BUILDING DIVISION FEES I (Certified copy,b herebyfurnished.the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE L�ilCnrtified copy V filed with the dry inspection division. CERTIFICATE.OF E(EMI7ION FROM WORKERS' GREASETRAP PAID V COMPENSATION INSURANCE SEWER-SANITARY.STORMEA200FT Date Recel t# (TAlseectlon need not be completed 11 the permit V(Drone hundred dollars ($1I Allyth WATER HEATER W/VENT/©ECTR ENERGY FEE Y N Icertifythat In the perforrtunce o(thewmkfor which this permit ls6sued, — I shall not employ any person In any nu nor eon to become subject to the WATER SYSIMA/TREATINC O Workers'Compensatlon Laws of California.Date PAID Z Applicant Date Recel t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT. should become subject to the Workers'Compensation provision.of the Labor TOTAL: W Code,you moat forthwith comply with such provisions or this permit shall be U G •dA deemed revoked. aCCONSTRUCTION LENDING AGENCY SEISMIC FEE . S— I hereby.firm that there is a matmctlon lending agency for the perform- ELECTRIC FEE 7 Zante ofthe work for which thin permit is Issued(Sec.3097,Civ.C.) TOTAL" (� O lander'.Name PLUMBING FEE LL I— Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W 01 coftilythatl have read this.ppliatbn..dstatethattheahlnformatla oven 11 lacorreat.I agree to comply with all city and county ordinanmand stale laws PERMITISSUANCE FEES PAID: } W relating to building mrutmction,and herebyauthorlurepresentaaveofthis F Z city to enter upon the above-mentloncd property for lapectlon purposes, ALTER OR ADDTO MECH. Date Recei til (Na)agree to save,fndemni fy an d keep harndeu the City of Cu portion P against Bablllties,judgments,mks and expenses which may in say way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against aid C n mnsequena of the granting of this permit. _9 AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX 454 n ofArm/Contractor to 7 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: ZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTin Date Revel t# mater it as deMnd by the Cupertino Municipal Code,Chapter 9.I$and the Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ YesNo Will the applicant m tore building occupant useequopment ordevocas VENTILATION PAN(SINGLE REBID) ISSUANCE DATE which emit haurdous air wmaMrunts a defined by the Bay Area Air pp�Y p ality Management District? BO)LER-COMP DIIPOR 100,000 BTU) P A D t Y..5No the ahave read the hazy Due ma lariats requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ifenla Health&Safety Code,Sections 25505,25533 and 25530.I APR 1992 understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. FT SQ. responsibility to notify the occupant of the requirements which most be met prior to tuuance of a Certificate of Occupancy. CI(Y UF CLarcnf Inv Owner or aulhorlud agent Date ISSUED BY: \ ��HN(X 4 TOTAL: OFFICE COPY