21040APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ed Identification
- PKMT NO. A
210 T O
Building Address:
. >.ln ry oo
owner-. ate: � -ojT
_/
CITY
-
OF CUPERTINO -BUILDING DIVISION
APPLICATION / PERMIT
RUILDING-ELECTRICAL-ILUMBING- MECHANICAL.
A A
I Ir l
c no- gor'. sate (JF Lic.No:
CATEGORY
CONTROL#
I A rchlted/ gioser: Lic. N.
L O
•QrY',,
�, PERMIT tit
'^ FEE
'' BUILDING PERMIT iNFO
Address:. G %%Vl FrnroaL.1�• B
_
,,ELECTRIC
PERhRTISSUANCG
i.. Q%
LICENSED CONTRACTOR'S DECLARATION
'whehectio rmthat lamlkensefth.Bupro,,io P.f. i.n.0 (commmc-
Ingwlth Seaion7000)af Dlvlelon3o(the Buslnenand ProfeeslonsCode, and my
license I. in full fo end effect 9
License Clam- LIeN�JLf /�s
Date ContraRar ,
ARCHITECPS DECLARATION
I understand my plans stu3 be used as publicremrds
Licensed Professional
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following resses.(5reloe 7031.5, Business and Professions Code: Any qty or
c ntywhichrequimsapermittommtma ,alter,improvgdemolbh,ormpair
anystmdurepdortoits1.. sane, alsomquirestheapplicant forsuchpermitto
file a signed statement that he Is llansed pursuant to the provisions of the
Contractors License law (Chapter 9 (rommeneing with Seaton 7000) of Dlvi-
elon3 of the Businnsandl' rofemionscode )orthat heleexempt there(romand
the basis for the alleged exemption. Any violation of Section 7011.5 by any
applicant for a permit subjects the applicant too civil penalty area more than
five hundred dollars ($.5Wj. •'
F1 1, an owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure le not intended or offered for
sale ( Sec. 70K Business and Professions Code: The Contractor's License Law
don not applyto an owner of propertywho builds orimprovesthereo0, and
who does such work himself orlhrough hlsawn employees, provided that such
Improvements are not Intended oroffered for sale. If,howevepthebullding or
Improvennent is BDid within oneyearofcompletion, the owner - builder will have
iy„},+arelm of proving that hedid not build or improve for purpose of sale.).
"L as owner of the ro
p pony, am exclusively Business and with licensed
mid actors to construct the project (sec. 7094 Business and Professions Code:
The Contractor's License Law does out apply to an owner of property who
Wild. or improves thereon, and who contracts for such pwires with a
cgngactor(s) B¢nsed pursuant to the Contractor's License Law.
ec
1_I I am exempt under S. B & P C for this reason
.,
APPLIANCESRFSIDEN7IAL
{Cis
OR DESCRB'DON
,
PANELS
2014000AMPS
JOVER 1000 AMPS
SQ. Fr. F1,O0R AREA
'
$ /SQ. Fr.
SIGNS ELECTRICAL
SPFGIALCIRCUIT /MISC
TEMP. OR POD Sf. J
• `
POWER DEVICES A
- 'Q
SWIMMING ISWIMMING L E
3
O EI'SSWITC ES +'
�' •G
VALUATION
(�(��
r
NE RESIDENT, LEC _ .
' k
STORIES
TYPE CONSTRUCTION
C d
QTY,
s, t
a / ` I
Y TOTAL:
' UA•7$ING'PERI111T.,.
P IT ISRU
ALTER -DRA A, VENT- WATER (EA)
..FEE `
��
OCC.CROIIIs
RES. UNITS
FLOOD TONE APN
t
" �. FEE SUMMARY
BACK FLOWTROTFGT. DEVICE
OUTSIDE FEES
DRAINS FLOOR, ROOF, AREA, COND.
FIXTURES.
FIXTURES. PER TRAP
SANITARY Y_ N.1�
RECFJI'I'd
Owner Date
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that I have a certificate of consent to wl( -inwrc, « a
3800, Lab C.) rken'Compensatlonlnsuranmors rertifled ropytheseof (Sec
SCHOOLTAX Y_ N
RECEIPT N
GAS FAMMT.Ab1 INCA OLTME5
i.0
PARK FEE Y N
GAS rA. 9Y$rEM-OVER 4 (EA) _
Colmcy an Y a
BUILDING DI VISION FGES
DING DIVISION
[2Cemfied copy is hereby furnished.
�fcemnea copy h rues with the dry inspection division.
the city
CERTIFICATE OF EKEMPrION FROM WORKERS'
COMPENSATION INSURANCE
Rhmsess.) need not Mcompleted If the permit Vf «ons hundred dollars
010(J ar1C9th ,
which Imoute employ any so as tobmers, subject the
I shake not employ any person In any manner n u to bemrrc subject to the
Workers' Compensation Taws of GllfomW . Date
Applicant
NOlicant APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compenszt Ian provisions of the Labor
Code, you must forthwith comply with such provisions or this permit hall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a canstmdion lending agency for the per form-
ance of the work for which this permit h Issued (Sec. 3097, Cis. C.)
Lender'sName
Lender §Address -
I red lfythat I have read this eppliad.. and state that the above information
I. correct. Iagmc to comply with a ll qty and county ordinances and date laws
relating to building constmme , and hereby authorize representatives of this
city to enter upon the above- mentioned property for Inspection purposes.
(We) agree to save, Indemnify an it keep harmless the City of Cu pectin
against liabiWies, judgments, mks and expenses which may in any way acme
against aid sty in naequence of the granting&this permit.
e
I� /�.- 1_ /' /_C_ _ ) .
GREASE /INDUSTRL WASTE INTERCEPTOR
'PLANCFIECK FEE
PAID
Date Recel HI
r
GREASE TRAP
SEWER- SANITARY -STORM EA. 20E-r.
WATER HEATER W /VENT /ELECTR
ENERGY FEE Y N
-
PAID
Date Revel tit
WAIL( SY51IN /TREATING
NEW RESIDENTIAL PLMB. SQ,FE.
-
-
TOTAL:
BUILDING
C�
SEISMIC FEE
.TOTAL:
O�
ELECTRIC FEE
6TY.
-
, :', MECHANICAL PERMIT,
..
",'FEE . -
PLUMBING FEE
x�
MECHANICAL PEE
j.
L, ,_
PERMIT ISSUANCE
FEES PAID:
'
ALTERORADDTOMECH.
Date Recei t#
AIR HANDLING UNIT (TO 1 0,000 CFM)
- SUBTOTAL:
AIRFIANDLINGUNrr(ovERiti000crm)
CONSTRUCTION TAX
sgnamrF of nppl�i aor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building «m pant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I I❑ Ynd Safety Code, Section 25532(a)7
Willtheapplleant or❑ futumbuildingoccupantuseegtiiproent ordevices
which moll hazardous air contaminants as defined by the Bay Area Air
Quality Management Distdd7
4 Yes No
haverea(t the hazy ous materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505,25533 and 75539. 1
understand thatJfthe building does not currently have a tenant, that It b my
responsibility to notify the occupant of the requirements which moat be met
prior to exu neof Certificate of Occupancy.
t )W- 64 -►—,_� °rd
l
EXHAUST HOOD M /DUCD
2,
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Rccei�tq
HEATING UNIT (OVER 109,000 BTU)
_
- TOTAL:
?
6 I
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
£•P 1 ( 1990
J
Y7-T-
ISSUED BY-. Crtt -^-"'" v —�✓
BOILER- COMP (3FR' OR 100,DM BTU)
BOILER-COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.Ff.
neror uthorized agent ate
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