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22269 AF'F'LIUAN I 1 U TILL IN INI-UKMAI IUN WI I MIN KLIJ LINt:1 — UJt_ t5ALL F'UIN I YtN UNLT -Building Project Identification PERMIT NO. Building Address:0 AA -- ' 22269 �'2 !v� � ner s _ one: A A *414"d CITY OF CUPERTINO-BUILDING DIVISION Contractor's Naame: y� /✓� Lic.No: APPLICATION / PERMIT C ` 'GK9 0 Yt> `�s�� BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL# Architect/Engineer. � Lu.No: OTY ELECTRIC PERMIT ME BUILDING PERMIT INFO Address: PERMITISSUANCE � 1:1 11 11LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION ingwith Section 7000)of Division 3 of the Business and ProfessionsCode,and my license is in full�force,�nd effect. ! ey PANES License Class 7w� Lic# �� y D �h Date — Contractor UP TO 200 AMPS ARCHITECT'S DECLARATION 201-1000 AMPS v• ��- O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ. . ZO Licensed Professional SIGNS ELECTRICAL T V 1 Q� ' Q� F¢w OWNER-BUILDER DECLARATION s Z W y SPECIALCIRCUIT , T W I hereby affirm that I am exempt f rom the Contractor's License Law for the O following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP METER OR POLE INST. pp county which requires a permit to construct,alter,improve,demolish,or repair o5a any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES �g Ufile a signed statement that he is licensed pursuant to the provisions of the 3 u Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- sion 3 of the Business and Professions Code)orthat he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES applicant for a permit subjects the applicant to a civil penalty of not more than CD O five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION Z ❑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 q sale(Sec.7044,Business and Professions Code:The Contractor's License Law r3 does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS who doessuch workhimself orthrough hisown employees,provided that such improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL: improvement is sold within one yearof completion,the owner-builderwill have the burden of proving that he did not build or improve for purpose of sale.). QTY PLUMBING PERMIT EEE FLOOD ZDNE APN ❑L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(Sec.704,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) bulids or Improves thereon,and who contracts for such pkojects with a FEE SUMMARY contractors)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECTDEVICE EJI am exempt under Sec .B&P C for this reasonOUTSIDE Owner Date DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_ RECEIPT# WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N ❑I hereby affirm that I have a certificate of consent to self-insure,ora RECEIPT# certificate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_ 3800,Lab CJ RECEIPT# Policy# 62 GAS EA.SYSTEM-OVER 4(EA) Com any BUILDING DIVISION FEES Corr copy fs hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy is filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. 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 an/person in any canner so as to become subject to the WATER SYSTEM/TREATING Workers'Compensation Laws of California.Date PAID Z Applicant NEVI,RESIDENTIAL PLMB SQ.Fr. Date Recei t# O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor TOTAL: LO Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE •OQ LI > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE L I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE D Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) ) O Lender's Name PLUMBING FEE L H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE ' IU I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: r N relating to building construction,and hereby authorize representatives of this city to 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# against liabilities,judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against sai Cityin c nseque of the granting f this permit. CONSTRUCTION TAX AIR HANDLING UNIT(OVER 10,000 CFM) Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARD TERIALS DISCLOSURE Will the applica re 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 Health 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 RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) { ❑Yes rd No JUN �J k N 1 7 1991 I have read the haza ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) t R the California Health&Safety Code,Sections 25505,25533 and 25534.I 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 City of Cupertino prior to issuance of a Certificate of Occupancy. !"' Owner or authorized agent Date ISSUED BY:� -% TOTAL: OFFICE COPY