26492APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
L I - ow DUCALPERMIT
CITY OF CUPERTINO1 .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT' IDENTIFICATION
NO.
264921
BUILDING ADDRESS:
SANITARY NO.
APPLICYGONSUBMDTALDATE
Parcel #
10460 Bubb Road uNlr» LOT«
A —Q r' t+
19L^l
OWNERS NAME: PHONE:
Berg& BergDevelopers
CONT ACTOR'SN LICNO:
NIC
❑
CONTROL
RCHITEC/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
El 9-
Roger`Bartgraves (408) 864-26*+
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IMreby uffitmthat l 3 ofthnxssoons andProfesio Chapter 9(m (commencing with
Scmien a and ofect. on 3 afthe Business mtl Prufnsidm Cade, and my license is in
Lira and effect.
APPLIANCES RESIDENTIAL
JOB D�
pgryplg
License Class
UP T0200AMPS
Date
Dam Convenor
Con
'
201- 1(xq AMPS
ARCheused as
I understand my plans shalt l ed used es public records,
SQ. FT. FLOOR AREA
$/S ..
i
OVER 1000 AMPS
SIGNS ELECIRICA
Licensed Professional
OWNER -BUILDER DECLARATIONSP
I CI 1 LSC.
I hereby affirm that I am CXCMPL from Ne Conbacmra License Low for the
P ETER O LE INST.
following traded. (Section 7031.5, Business and Pmfessions Code: Any city or county
which requires a permit to cdnstmq aper, improve, demolish, or repair my strveture
priarmits6s... re. Wso requites theepplicant for such permit
RDEVICES - ---
thatheislicensedpursuanttotheprovisionsoftheContractor License Low (Cb+ptef
9(commencing with Section 0000) of Division 3 ofthe Business and Rofessions e)
: S I M•„Q E IC
VALUATION
or dm he is exempnherefram add the hands for thealleged exemption. Any ..... r .1.
Section 1031.5 by any appl arm for a Permit subjects the ofPlieenuoacivil Pena of
1 ��
OU,I,LCI,S ZSNITryryurr�S'Fl R
-
not more than five hundred dollars ($500).
❑ I, asownerophepropeny,ormyemplayeeswirhwegexmthei...lecompemad.n
NEWRaXAgtM SQ. PT.
STORIES
TYPE CONSTRUCTION
will dothework,and the structure isnot intended orefferal forsale(Sec. 7044, Bttdhas '
and Professions Code: The Contractor's Lareme Law docs not apply to hqs¢wner o
`
pn�peny whobuildsdrimproves thereon, andwhodoeaauch workhimselfmflinatuthhis
own employces,providWthat such improvements arenot imendedoroffered for sale. If,
OCC.GROUP
RFS. UNITS
TOTAL:
however, the buddingor improvement is sold withinone year afcompletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
sale.).
Elhas awnerofthe pmpeny,amexduaivelywntmning wits licemedcontrxtorsto
WOOD ZONE
APN
comtmct the project (Sec. 7014, Business add Prodessimts Ceded The Contractors
License Law rostrum apply to anownerof property who builds or improves thereon,andPERMIT
ISSUANCE
who cantmcts far auch projects with a comma mr(s) licensed punuoat to the Commemr s
Li.. law
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
❑ 1 ten exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT. DEVICE
SANITARY Y N
RECEIPI'N
Owner Rate
DRAINS - FLOOR, ROOF, AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
nIhave
3[}Iherebypenrtnon Inarveaceniftcamorcamennoxl6ec. 38or"In C.) which
kcri Compensation lmurmaoraurtiGW copy Nercof(Stt.Jg00. LabCJwhich
RECEIPT»
FIXTURES - PER TRAP
PARK FEE YN
coven all la se's un der this permit
Policy N
RECEIPTp
GAS -EA. SYSTEMI INC.40lJTUTTS
O
BUILDING DIVISION :S
70
Com PenY Rey -u }e TBde�i y —
.Q. Certified copy i4ltere y famish
GAS- EA. SYSTEM OVER 4(EA)
PLANCHECK FEE
GREASERNIDUSTRL WASTE INTERCF-PI'OR
GRADING FEE
CediGW ropy is Glut wit flu, city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS ME
COMPENSATION INSURANCE
SEWER- SANITARY - STORM FA. 200FT.
ENERGY FEE
(This section need not hcompleted if the pemdr isfmmehundrW dollars(5100)
or less.)
WATER HEATER W/VENT/ELF-CIR
I certify that in the Pe 01111 eJIW of the work for which this permit is issued, I shall
not employ my person in any manner so or to become subject to the Worked'
PAID
Conrpensation"veof California. Date
WATER SYSTEMTJREATINGme
Receipt»
Applicant
NOT ICE TO APPLICANT: If, after making this Certificate of Escmption, you should
NEW RESIDENTIAL- PLMB. SQ. FT.TOTAL:
become subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SF-ISMIC FEG
CONSTRUCTION LENDING AGENCY
1 hereby Wfirm that there iso commanotan lending agency for the performance.(
the work for which this permit is issued (See. 3097. Civ. C.)
ELECTRIC FEE
Lenders Nome
'
QTY. `� MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I certify that I have read this epplic lid. attitude that the above informed.. is
rrect. l agree to comply with all city and county ordimnces andm, laws relating to
PERMITLSSUANCC
MECHANICAL C
huildingconstwnion, and hertby amhorize repmeenutive.s of Wscity mcmcr upon Ne
above-mentioned Property for inspection purpose..
ALTER OR ADD TO MECH.
CONSTRUCTIO TAX
(Wed agree to save, indemnify and keep harmless the City of Cupertino against
lobilities,judgments, costs and expenses which may in any way accrue against said City
AIT HANDLING UNIT (TO 10.000 CFM)
in Co."... of the granting of this permit.
AIR HANDLING UNIT (OVER 10.000 CFM)
Signature of ApplicanVCommetor Date
BXHAUST HOOD(W/DUCD
PAID
HEATING UNIT CM 100,00) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
HEATING UNIT (OVER 100,000 BTU)
Will the applicant or future building demeanor show or handle hazardous material
as de6gW by the Capmin. Municipal Code, Chapter 9. 12, mdthe Health end Safety
VENTILATION FAN (SINGLE RESID)
Carl Stttt� ]5532(x)?
�Yo ❑ No
ISSUA CE DATE
Will theapplicantorfumrebuildingmcupmtuxcquipmrnt ordevicsi whichemit
BOILER- COMP(3HP OR 100,000 BTU)
-
BOILER - COMP(OVER 100,0110 BTU)
humWous air comaminols as deGnW by the Bay Awa K. Qaelhy Management
P JS 0
NEW RESIDENTIAL. MECH. SQ. FT.
Yes ❑ No
1 have wad the hazardous matenuls requirements under Chapter 6.95 of the
le &Sate 77de, Sections 25505, 25533 and 25534. I understand that
SEP - 7 199
CCel'
a it n des nm c e lily have a Icnent, that it is my responsibility to notify the
cu n of esquire a which must be ten pram m issuance of a CeniTieam of
C., �/ i ser ,^
ISSUED BY:
wncr,ituthan gent Data
TOTAL:
OFFICE