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23015APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project IdenUHcation Bnilding AddreO�' .� � srrc PERMITNO. 23015 am1e: - one: CITY OPPLIC TTION I DINGPER DIVISION APPLICATION I PERMIT APPucATr6770W9TrrA75= L 1^Z�_ R( �'l conhat Mame: ur.No: OV d BUMDINGELECnUCM PLUMBINGMECHAMCAL CATEGORY CONTRO N y rchltect/Engineer. Lk. No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERMIITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby Affirm that l am licensed under provislonsof Chapter 9(commen Ingwlth SecHon7000)of Divison3 oftheBminessand ProfeaslonsCode,and my licenseIs In full force and effect. APPLIANCES -RESIDENTIAL JOB DESCRIPTION PANELS Llcer eClam�}�)� Lie.N Date kyr?CantnRar— ARCHITECT' ECILARATIO I understand my plain shag be used m publle records. Licensed Profe®Wnal LM TO 2DOAhVS , 201-1000AMI'S OVER 1000 AMPS 50. FT. FLOOR AREA $`/SQ. FT. 2v �► SIGNSELECTRICAL OWNER -BOLDER DECLARATION I herebyaffirm that I am exempt from the Conlratoes License Law for the following reason(Setion 70715, Business and Pro/calms; Code: Any city or munlywhichrequlresapermktomrslmt,alter,bnprove,demo h,ormpair SPECIALCIRCUI Tpl,(P.METEROR E anyslr mptlortolUls once,akorcquireatheappllantforsuchperMtto Ilk a signed statement that M k licensed pursuant to the provisions of the Contractor's License Law(Chapter9(mmmencing with Section 7000) of Divi. sion3 of the Businesaand Profmiom Code) orthat hely exempt themfmmand the bask for the alleged exemption. Any violation of loon 7015 by any app0ant fora permit subjects civil applicant to a vil a penalty no nvre than POWERDEVICES SWIMMING POOL FL OUILETSSWFTCHESE%7'URI S VALUAT^ION five hundred dollars ({500). ❑ 1, as owner of the property, or my employees with wages as their sok NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION compensation, will do the work and the stmcturc k not Intended or offered for vie (Sec 7064, Business and Pmfenimu Cade: The Contractor, License Law .. does not apply to an owner of property who Wilds or improves thereon, and who does such work himself or through his own employees, provided that such OCC.GROOa RES. UNITS Improvements are not Intended oraflered foreale. If, however, lhebulldlrg or Improvement k sold within one yea rofcanpletion, the owner -build erwill have te�rrden of proving that he did wt WILL or improve our purpose ofsale.). u L as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: TOTAL: PLUMBING PERMIT FGE Q'rY. PERMIT ISSUANCE FLOOD ZONE APN The Contractor's License Law does not apply to an owner a property wh builds or Improves thereon, and who contract Iw such p�ojsata with a coator(s)Ikented punuantrothe Contntor's License Law. I__I I am exempt under Sec.B k P C for thisreaso ALTER -DRAIN kVENT'- WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE OUTSIDF FEES DRAINS FLOOR ROOF, AREA, COND. FIXTIIRFS PER TRAP - SANITARY Y N RECEIPT N Avner Date WORKMAN COMPENSATION DECLARATION 01 hereby affirm ce that 1 have • rtifte to of consent to self -Insure, or cenifkateof Workers'Compemationlr mnmoramtlfiedmpythereo!(Sec. 3800, Lab C.) SCIgOOL TA% Y N_ RECEIPTNY CAS EA. SYSTEMf-]INCA OUTLETS PARK FEE Y N Policy p RECEIPT M GAS EA. SYSTEM -OVER 4 (FA) Cam any - BUILDING DIVI FEES [rCerFfIxfiled copy Is herebyfurnished.the ❑CertBled mpyla(Iled with the tly Inspection division. city GREASE/INDUSTRL WASTE INTERCEPTOR PLANC1i�FEE /y naNsa `y1� S`/T1]aJf GREASETRAP CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need met M complied ff the permit la farorre hundred dollars (E100)orlen.) I certlly that in the performance of thewmwhichbl klor which this permit Is issued, 4�j PAID Recei —1 SEWER-SANTTARY-STORM EA. 2DOFT. WATER HEATER W/VENT/E.ECTR •E EN Y N — Ishall na employ any person In any manner m as to be ©me abject to the Worker Compensation Laws of California. Date WATER SYSTIM/TREATING PAI AppNEW NOTIC NOlicant MI'LICANT:If, afterrwking this Certificate of Exemption, you should become subject to the Workers'Comperastlan provisions of the Labor Dale Reeel Ip RESIDENTIAL PLMB. SQ.FT. TOT Code, you must forthwith comply with such provisions or this permit shall be deerred revoked. BUILDING SEISMIC FEE CONSTRUCTION LENDING AGENCY I herebyalffrm that them is a commotion lending agency for the perform ance of the work for which this permit Is Issued (Sec. 3097, Cly. C.) Landers Name Landar's Address I certilythat I have readthkappgmtlonvul nate thattheabove In(omation kturret. I agree to comply with all cityand county ordinances and Mate laws ...ting to building com(rurctlon, end hereby authodu representatives o(this TOTAL: ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PLUMBING FEE MECHANICAL FEE PERMIT ISSUANCE FEES PAID: city to enter upon the above-mentioned property for impectlon purposes. (We) agree to save, indemnify an d keep harmless the City of Cupertino against MbilBka, jrdgmenk, mss and expenses which may In any way accrue agalost sald City In mnaAq. ence of the granting of this permit. ALTERORADDTOMECH. Date Rl [q eeeP AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Cortmtar Data FxHAErsr HooD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT (TO 101,000 BTU) Will the applicant or future budding occupant store or handle hazardous micrkl as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the Health and SafetyCade Section 25532(4P ❑ Yea NN. Date Recei fp HEATING UNIT (OVER 100,000 BTU) TOTAL: VENTILATION FAN (SINGLE RESID) ISSUANCE DATE Will the applicant or future building occupant use equipment or devices which emit haeardous air contaminants as defined by the Bay Area Air Quality Maragcmcm District? Yea' es No have read the hazardous materials requirements under Chapter6.9i of P A I D BOILER -COMP PHI' OR 100,000 BTU) BOILER.COMP(OVER 100,000 BTU) the Gldernia Health k SafetyCode, Sections 25505,25533 and 25534.1 understand that lithe buildingdoes not correk nlly have a tenant, that it my responsibility to rally the occupant I the rnqulrements which must be oat DEC 23 1991 NEW RESIDENTIAL MEIN. SQ.FT prior to kwuanm of a Certificate of Occupa rry. CII r OF CllPtnulvu ISSUED BY: Owner or authorized agent Date TOTAL: OFFICE COPY I