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24623APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUIL TNO - ELECTRICAL. PLUMBINGROJECTBDENTIFIC BUILDING DIVISION APPLICATION/PERMIT NUILpING PROJECT IDENTIFICATION PERMIT NO. 24623 BUIL01 GADDRESS: I e VA ���� L` A w IT# LOT If SANITARY NO. APPLICATION SUBMITTAL DATE r 21 C t Z OW NAM V PHONE: CO TRACTORS NAME: Ir 17 ����� LRR eqsT N/C CONTROL# AR HITELTIENGINEER: LIC NO: AD RES 90 CAdwll Cz CONTACT: PHONE: TheAsT LecT c QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO BO El PLUMBME❑CH PERMIT ISSUANCEEl /� LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7") of Division 3 of the Business end Professio� �� Code, and my license is in Licefall tome and eefffeec-t� �/� Dthe ns I '/�_ Cont#ractor �� APPLIANCES - RESIDENTIAL. JOB DESCRIPTION PANELS UP TO 200 S 201 - IBM AMP ARCHITECTS DECLARATION 1 understand my plans shall be used as public records. OVER 1000 AMPS SQ. FT. FLOOR AREA , Yy p © IN w1 , v ILIA p T E R $/SQ. FT. SIGNS ELECTRICAL Licensed Professional OWNER -BUILDER DECLARATION I hereby airmt that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Cade: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure priorto its issuance, also requires the applicant forsuch permit to file asigned statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 9000) of Division 3 of the Business and Professions Code) or that he is exempvherefrom a ad the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner ofthe property, or my employees with wages as their sole compensation, will do the work, and the structure is not imended oroffered fm sale (Sec. 0094, Business and Professions Code: The Conamemes License Law does not apply to an owner of property who builds orimproves thereon, andwhodoessuchwork himselforthrough his ownemplUces,provided that suchimpromments arenotimmndedoreffered fintode.If, however, thebuilding or improvement is sold within oneyearefcompletion, the owner- builder will have the burden of proving that he did not build or improve for puryose of sale.). ❑ I,asownerofthepmo ny,amexclusivelyconvociingwiNlicensedcommcmrsm 04 construct the project (Sec. 94, Business end Professions Code:) The Contractor's Li cense Law d nes not appl y man owner of property who bui ld s or improves therenn, and wbocmtlmcts forsuch projects with a comtmeror(s) licensed pursuant to the Contractors License I.. ❑ I am exempt under Sec. , B & P C for this ..no SPECIAL CIRCUITIMISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC ALUATION OUTLET$ - SWITCHES -FI%TURES NEW RESIDENTIAL ELECfR _$Q. FT. . STORIES OCC. GROUP TYPECONSTRUCIION RES. UNITS TOTAL: 70 QTY, PLUMBING PERMIT FEE FLOOD ZONE APN L PERMIT ISSUANCE PETER - DRAIN&VENT- WATER(G SUM[h FEB SUMARY BACK FLOW PROTECT. DEVICE O TSIDE FEES SANITARY YN RECEIPT# Owner Dam DRAINS - FLOOR, ROOF,ARG,COND. WORKMAN COMPENSATION DECLARATION ❑ IImmbyaff.. thmlhave ecenificete of consenue sel4insare,ora.ciificnteof Workers'Compensation Insurance or acertified copy thereof(See. 3800, Lab C.) which covers all employee's under this permit Policy # SCHOOLTAX YN RECEIPTp FIXTURES - PER TRAP PARK FEE Y N RECEIPT # GAS - G. SYSTEM -1 INC. 4 OUTLETS BUILDING DIVISION PEES Company GAS -G.SYSTEM-OVER4(G) PLANCHF.CK FEE ❑ Certified copy is hereby furnished , I/ Certified copy is fledwith the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed ifthe permit is for one hundreddollars($100) orless.) I certify that in the perfomtance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Lawsof California. Date Applicant GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE GREASE TRAP SOILS FEE SEWER - SANITARY - STORM EA. 200FT. ENERGY FEE WATER HEATER W/VENT/F.LECTR PAID Date Receipt# WATER SYSTENUTREATING NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction, lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) lenders Name NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: - BUILDING FEE SEISMIC FEE TOTAL: ELECTRIC FEE 3 QTY. MECHANICAL PERMIT FEE PLUMBING FEE Lemdels Address I cattily that 1 have read this application and state that the above information is rect. I all m comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives ofthis city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs and expenses which may in any way accrue againstsaid City in co sequence of the grwti of Nis permit, e PERMIT ISSUANCE MECHANICAL FEE ALTER OR ADD TO MUCH. AIR HANDLING UNIT (TO 10,000 CFM) CONSTRUCTION TAX AIR HANDLING UNIT (OVER 10,000 CFM) Sign a-{tu/reMo/f A pjff1i u7natrachonC// Dute{/\ AW HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertin;7M nlcipal Cade, Chapter 9.11, and the Health and Safety Cade, Section 25532ful ❑ Yes o Will the appliconmrfmurebuildingaccupantuse<quipmemmdeviceswhichemil hazardous air contaminants as defined by the Buy Area Air Quality Management District? ❑Yes No 1 have read the hazardous materials requirements under Chapter 6.95 of the Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the req 'remean wh' h must he met prior m issuance of a C rtifo to of Occupancy. U/1-1 ��� EXHAUST HOOD(W/DUCT) PAID Date Receipt# HEATING UNIT TO 100,000 BTU) - HEATING UNIT (OVER I W OW BTU) TOTAL: d VENTILATION FAN (SINGLE RESID) BOILER - COMP LIFE OR 100,000 BTU) �lISSUANCE,DATE DEC 15 1992 CI I I Ur (:UYLn 1 1110California s,� \. ISSUED BY: 5J BOILER - COME(OVER 100,000 BTU) NEW RESIDENTIAL MECH. SQ. PT. Owner or authorized Owner or authorized agent Date TOTAL: OFFICE