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23824 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification 7 PUMT NO. Building Address: , LCOIA �t 23824 wners ante: one: APPLICAJIUN hUbMil IALA p)t E v ( I CITY OF CUPERTINO-BUILDING DIVISION Conlracro%,Name: _ Lie'Ne: APPLICATION I PERMIT 6 To- Is Z- t '+1'6'1 BNLDINGELECTRICALPLIJMOING-MECIIAMCAL I - CATEGORY CONTROL N I * Architect/Engimer. . V Llc No: ' �,s QTY FEE BUILDING PERMITINFO - Address: (� go; L Smc PERMIT ISSUANCE ❑ 1:1 ® ElLICENSED CONTRACT'OR'S DECLARATION I hereby affirm that lam licensed under provisions of Chapter9(commenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION l'ngwith Srcdon7000)of Dlvbion3 ofthe Businessand ProfcandensCode,and my icense is In full to deffect p / PANELS N License ClassG-S/a Lic.p ! 1_�_ �D e - Date�a2- Contngar!Q(9 & I ARCHITECTS ECLA ATIO 201-1000 AMT'S C O I understand my plans shall bs u as public recods. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Fr. z U Licensed Professional _ SIGNS ELECTRICAL n p 6 6 re OWNER-BUILDER DECLARATION ��" 1 Ij �l /N II Ike �n �n SPECIAL CIRCUIT/MISC A 1L� E PJ f., Z Thereby affirm that]am exempfrom the Contractor's License law for the z P following reason.(Section 70315,Business and Profesloru Cade:Any city or t„ /l OZf E TEMP.METER ORIOLE INST. JR `. K� county which rcqulresapemdtroconstruct,alter,improve,derrolbh,orrepalr, �JI aanystructure priortoits Issuance,alsorequlreslheapplicant for such permit to POWER DEWCFS O file a signed statement that he is licensed pursuant to the provisions of the7441 Q3m't^ ContactoraLicenselaw(Chapter9(corrurencingwithStollen7000)ofDivi- SWIMMING POOL ELECTRIC pHT F�Cn sion 3 ofthe Business and ProfessionsCds)orthat he is exempt themfromand ' the basis for the alleged exemption. Any violation of Section 703L5 by any g $ GUILE TSSWTTCHESF(XTURES applicant(ora pemdt subjectathe applicant to a civil penalty d not mem than c.pa�o five hundred dollars(SM. NEWRESIDENTIALELECTR FT. I,as owner of the roe `•'Q' STORIES TYPE CONSTRICTION Q X.4 O nation,will do the work nam ewrn�ree Isom with nor door ole1ma for " - 5�❑ sale(Sec.70K Bmbfiesi and Profeslons Code:The Contractors License Law V' F does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNITS who does suchwork himself or through his own employees,provided that such Improvements arc not intended oroffered forsele.If,however,thebuilding or TOTAL: ' Improvement bsold within oneyearofcompleRoo,the owner-Wudder will have Hilden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE conuach rs to construct the project(Sec 7014,Beimain ad Professions Cods: The Contractors License law does a&apply to an owner of property who ALTER-DRAIN k VENTWATER(FA) Wilds or Improves thereon,and who contracts for such p(ojects with a FEE SUMMARY c tractors)licensed Pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVICE ❑I am exempt under Sec B k P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ Owner Date RECEIPT N _ WORKMAN COMPENSATION DECLARATION FD(TURE&PER TRAP SCHOOLTAX Y N ©l hereby affirm that 1 have a certificate of consent to self-Inmre,or a RECEIPT N certificste ofWorkers'Compensatlon insurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS _ rs9( PARK FEE Y N 3800,Iab C.) f[![ RECEIPT It Policy p GAS EA.SYSTEM-OVER 6(FA) Com any BUILDING DI VISION FF.i[5 ECenlfied copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE ISI Certified copy is filed with the city inspection division. ' WW CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT. Date RCCeI t# (Thlssection need net be completed if the permm U forom hundred dollars (8100 .Ifine.) WATER FIFATFR w/VENT'/FlECTR ENERGY FEE Y_ N_ I mtlifythat In the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to becorre subject to the WATER SYSTEM/TREATING Workers'CompensaHon Laws of California. Date PAID - zZ Applicant NEW RESIDENTIAL PLMB. SQFI'. Date Revel t# Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Fshould becme osubject to the Worker: w Compeatlon provisions of the Labor TOTAL: cc N Code,you must forthwith comply with such provisions or this permit shall W BUILDING FEE LU 9 deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE CL Thereby affirm orkforthat which this constpermit h tionIssued lending agency 7,CIv. .) perforrry _ ELECTRIC FEE -C) Z Lancerthe Name for which this TOTAL: permit V Luued(Sec.3097,Civ.C.) U O eneeraName PLUMBING FEE LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW heal(ythatih vereadthisappllationan Oatethattheaboveinformation .W Isconect.l agree to comply witha116tyand countyodirunces and state laws PERMIT ISSUANCE FEES PAID: '} OL relating to Wilding construction,and hereby authorize representatives of this H N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Z love)agree to save,indemnify an d keep harMess the City of Cupertino Date Receipt# V against liabilitles,judgments,coasand expenses which may m any wayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: against said City in conaryuence of the gr t' of permit. ' N a 6YIZ` S AIR HA NDLING UNIT(OVFR 10,000 CFM) CONSTRUCTION TAX 5 mhumo Applicant/Contractor Dam 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,"BTI)) Date Recei t# material as de0nd by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety Code Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yes []No Will the applicant or futumbuilding occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE which emit hazudovs air contaMwnteas defined bythe Bay Area Air E'f A I D Quality Management District? BOILER-COMP QHPOR 100,000 BTU) r I� GYrs ❑No havcread the hazardousmaterials requirements underChapter6.95of BOMER-COMP(OVER 100,000BN) the Gll(omullahhASafety Cde.Sections 75505,7x533 and 75536. I JUN12 1992 understand that if the Wilding does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT responsibility to notify the occupant of the requirements which must be treat prior to Issuance of a Certificate of Occupancy. CITY Ut- LVI'CY1111V`U Owner or authorised agent Date TOTAL: ISSUEDBY: UUCC OFFICE COPY