21683 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Project Identlflcation. PERMITNIO..,1 h'1
Building Address:D G Y Y I V V j^'{
3
wneraams _ ho A ,
1 ex CITY OF CUPERTINO-BUILDING DIVISION ' .-
c°^tr o .
am e: ,v5 APPLICATION /PERMIT.
0
BUILDING-ELECTRICALnL BINE MECH_AMCAL CATEGORY CONTROL p
Archi / gineer: - Lk:+Nm .,
4 r i4 + yin i xi e 11qq it r�. t e ati J'."BUILDyING PERMIT INFO ti "s
i, Q3Y ,t- ItS LECyTRI�KPERMITs. d . bio FECS1 I4 t. -.i
Address: - , �V, _
cLax,i PLUMB K=n .
PERMITISSUANCE I - ❑ n �. ❑..;,
•+ "LICENSED CONTRACTOR'S DECLARATION LF`J
Thereby eHirm nhatlam licensed under provlsmns of Chapter9(comm c- APPLIANCESRESIDENTAL JOB DESCRIPTION
Ina.seiSectbn�)of defLicfeon3ofthe Businessand Pro(esslonsCode,and my � -
LimaIsis(u0f rc5 anddisc[., r PANELS j•^I ��
License Class Y9. p
Co
-- Date Contractor
ARCHITECT'S DECLARATION 201-1000AMP5
a4 I bre
entandenpmcashallbeused�aspubhecords OVER1000AMPS, - - SQ FT FLOOR AREA $/SQ.Fl.
CO I ,
2(1
Licensed Professional SIGNS ELECTRICAL
'OWNER-BOLDER DECLARATION
- -SPECIALCIACUIT/MISC
�x p, Ihngrason.(hatlam31.5,Bexempt usiness
Contractors Code:Law(g the -
oo rw
following reason. 7Ui15,Bwlness asci Pro(essiona Code:Anytltyr
FZ ty 9u P° P P TEMP.MEITR ORPOLE INST. ',f+
� octan who:hrc iresa rmlttocorenroct eltep bn rove,demolish,or air ��ii fail
any.tmcmldpdort.its Lssuence,al mquirestheappilcantforsuchpermitto POWER DEVICES
Bin a signed statement that he is licensed pursuant to the provisions of the
Ok Contractor's License Law(Chapter 9(commencing with Section 7000)om(Dlvl- an
Bion 3 ofthe Business and ProfeadereCode)or that he is,exempt therefroand SWIMMING POOL ELECTRIC. AB
!�0
14' the basis for the alleged exemption. Any violation of Section 70315 by any "'+- •'
applicantforapemde ts
tsub) theapplicant to a civil penalty of got more than OUTLETSSWITCIiESFIX'CURFS
five hundred dollars($500). NEW RESIDENTIAL ELECTR
�g ❑I,as owner of the property,or my employ es with wages as their sole SQFT. ^' n2I1CTION
compensation,will do the work and the structure 0 not intended oroffered for
sale(Sec.7044,Bususaw.nd Professions Code The Cot otes License Law -
$$ doe.not apply to an owner of property who builds or improves thereon,and OCC;GROUP RES.S1M'f5
who does such work himselforthrough his ownemployees,provided that such
t Improvements are not intended oroffered for sale.If,howevegthebuilding orTOTAL: _
i provementissold withineneyearofcompleliomtheowner-builderwiil have TvA.',111,' 1t t+t
tl�S rden of proving that he did'not build or improve for purpose ofsale) QTY. i" t .;PLlJivt$INGPEAMIT pLOOD ZONE APN
i LJ S as owner of the property,am exclusively contracting with Licensed ppTTUANCE - '
i mntracierstomnstructthe project(Sec.7044,'Bualneas and Profenlgns Code: , -
The Contractor's Lt...Law does rel,apply to an at of Property who ALTER-DRAIN&VENT-WATER(EA)builds,or Improves themor,and who contracts for such Projects with a _ -
tactor(s)Icensed pursuant to theeontractor4Lkense law. ., 'g•k t>`,ryt t??'FEE SUMMAAYp ti i �,"'
BACK FLOW PROTECT.DEVICE.
oq0.[ ° •' "'^
I_J I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,CON I. SAMTARY Y - N
. Owner Date RECEIPT=
WORKMAN COMPENSATION LA{EATION FD(.TURFS PER TRAP SCHOOL TA% ,Y N
❑ Jlereby affirm that This-_a_grti IO ..r.�saM to_If"nsutt;'or a
-n,,11'-Ie�f crops tl I ertifled copy
thenrof(Sec. RECER'TN
3BOB'ia C� CAS EA,SYSTEhf-1 WC.40Un.EfO - PARK FEE Y_ N
Pollry p' .- RECEIPT p
Com an t - GAS EA.SYSTEM-0VER4(FA) '
Y - - BUILDING DIVISION FEES
�Cer[10ed copy
is hereby furnished - y GREASE/INWSTRL WASTE INTERCEPTOR' PLANCHECK FEE
❑Certified ropy is ftkd with the city impon ion division
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAPy PAID
COMPENSATION INSURANCE orSEWER-SAMTARY-STORM EA.200FP. Date Recei t#
_
5100)or
need not be completed if the Permit (Drone hundred dollars
IS100)wless.) WATER HEATER W/VENT/ELECT11 ENERGY FEE Y N
9 certify Nat In the performance of the work forwhich this permit is issued,
I shall not employ any pe In any mann t become subject(o the WATER SYSTEM/TREATING PAID Workers'Corn sues so Ilfolpl! ro - 5—`7/ ,
OZ Applies ✓J NEW RESIDENTIAL PLMO, Q.FC. Date RfCei IN
Z L7NOnCEf�APPL CA If
after, dog this Certiflrate of Exemption,you
should become.ubject to the W. an'Compersation provisions of the Labor - - - - TOTAL:
N Code,you at forthwith comply withsuch provislon,or this permit shall be
.7 deemed revoked.
BUILDING FE
W
G CONSTRUCTIONS LENDING AGENCY ' SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE-
3 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) ,. TOTAL '
O.O, Langer.Name PLUMBING FEE
LI: Lender's Address - - QTY.', ; I MECHAN[CAL:PERIMIIT " E"` MECHANICAL PEE
O W I certifythatl have read thisapplicattonand statethartheabove Information ,
(L iscorrectbuilding complywRh all ndhereb countyordinances
representatives
and state laws PERMIT ISSUANCE FEES AID: -�
}' relatingoenobupon the abouctioryioned prop authorize repreaenpurposs.this [ �6 �,, '
H Z cityW)aree to theabove-menHoned propertyforimpaction purposes. ALTER OR ADD TO MECH.
_ (We)agree save,tindeencify mrsandkeepharmless she in aof ayammo - Date •Receipt#.
against liabilities judgmequencetof the
expenses which may in enywayaicrue AIR HANDLING UNIT(f010,000 CFM) -
' SUBTOTAL:
against said City In consequence o(the granting of this permit. _
-, -„ AIR HANDLING UNIT(OVER 10,000 CFM) � � � CONSTRUCTION TAX!
Signatureof Applicant/Contractor Data E%HAUS'r HOOD(W/DIKE, - - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
WlRnha applicant orfuture building oavpant store or hand le hazardous, HEATING UNIT(TO 1 WWO BTO)' Date RCCCIDtff '
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the'
Health and Safety Code Section 2SO2(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
.. ❑ Yes.- .. `❑No ,' -
Willtheapplicantor(uturebuBdingocctipan(use equipment or devices VEMIILATION FAN(SINGLE REBID) ISSUANCE DATE
which Me
t hazardous air cornmannts as defined by the Bay Area Air -
QuxllnyM gemort District? BOILER-COMP pHP OR 100,000 BTU)
❑Yea n No END
i"'1 havere dthehazarr ous materials requirements under Chapter 6.95 of, BOILER-COMP(OVER100,000 BTU)
,rhe California Health&Safety Code,Sections 25505,25533 and 25534.•I -�fl1t1 La
understand that lithe budding does not currently have.tenAR Vant,that it is my NEWRESIDFNTIALMECH. SQ.FT. 44 -
._responsibility to notify the occupant of the requirements which must be met -
priortoissuanceofaCe,ificateof Occaipanry.
Owner or authorized agent Date
.TOTAL: ISSUED
OFFICE COPY
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bT ,; + ,,`w^�a$ `1S #i Tit�.`�`.n ;f�8��•3ia��i i�Co-fi:5�.1;'�sT' Tti� , Input Permit,N'ir AT'0$
PERMITM B0667 ARCHITECT VALUATION: 55000 '1
APN: 32601007 LICENSE p'. ISSDATE: O
SITUS STREET: BARRAN SUBDATE: 5/27/99 PLCHKDONE.
SITUS ND#: 10955 TYPE: RSX LATE CODE:
AVE,CT,ST.RD: DR BLDGDEPT:
N,S.E.W: DESCRIPTION: SHED
I : ENGDEPT:
NOd
CU
ZIP-. PLANDEPT:
CITY: * r
P. CATEGORY
95014 . Y CMA:
' CATEGORY 1 LTRFIRE:
LOTH 0 DATEDUE: 6/3/99 SANDIST:
ID: WARD CommereW HLTHDEPT:
OWNER: WARD MARJORIE AND LLO CA-sgGllq: TOSTRCTETALNG::
OWNER 21849BEAR CREEK RO CE-sgUltp. INS To LD
AL
ADDRESS'. LN sgUIl01.
CITY,STREETZIP'. LOS GATOS CA 951 pexidential n'tI
PHONE:
RNsgpltU 560 SYS
CONTRACTOR F REs : 10
{6earehh Address
LICA: RUfrsq#it#9gllp 0
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VlewaL�.x<� vl ^ 'r wn le a@r psi cr sC(—'d ��F7. 77 NUMI r��
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