285341. APPL.ICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
_ PERMIT NO. ^ q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
28534 8 5
L VX JK 4
BUILDING PROJECT IDENTIFICATION
_
BUILDINGSD -
SANITARY NO.
APPLICATION SUBMITTAL DATI
-
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OWNER' yHQTJp
L•`fV1
CENTRAL OR'S NAME: LIC NO:
NIC
❑
CONTROLp
ARCHITECMNGINMR: LIC NO:
ADDRESS: a�
r"Smaww"Aptim *0
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (InitSep
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hcrtby aRna that I am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
wish SWian70M)of DivisM3 flhe Businessand Professions Code,androyhomse is
in full forceendef 1. -21327?
Licen Classlassq_. Lie.MZAfi
Dam Gommemr
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[I ADDITION [D PLUMBING R&PIPE
PERMIT ISSUANCE.
APPLIANCES - RESIDENTIAL
ARCHITECTS DECON
� I understand my plans shall be used as public mounds
.MULTI -UNIT -❑STRUCTURAL
MODIFICATION
PANELS
UPTO 2M AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
El REMODEUREPAIR [D DEMOLITION '
❑ OTHER
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 and carhop, from the Contractor's License Law for the
following reason. (Section 7071,5, Business and Professions Cade: Any it, or county
which require a permit to cnnslmct, alter, improve, demolish, or repair any structure
201-INX)AMPS
OVER I(If11AMPg
SIGNS ELECTRICAL -
_
prior to its isevurce,lsorequires the upplicaut for such permit to fileasigned statement
SPECIAL CIRCUITIMISC.
'
that he is licensed pursuant n the provisions of the Convector's License Law (Chapter 9
TEMP. METER ON•INST. s
COMMERCIAL,
(commencing with Sermon 70M) of Division 7 offle Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7071:5 by any applicant for a permit subjects the applasen to a civil Penalty of
not mom than Eve hundred dollere(55(N). r
❑Las owner of the progeny. nr my employecs with wages os their sole compensa,inn.
will do the work and Ne stratum is not internal m.fficed for sale (Sec. 7044, Business
❑ NEW BLDG/ADDITIONMOLITION
❑TENANT FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMINGPOOLEL RIC
and Professions Cade: The ConwcmYs License Law does not apply to an owner of
011H.EI'S-SWITCH-FIXTURES
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENT14,L EL SQ FT.
SQ. FT. FLOOR AREA
5/SQ. FT.
We. IL howevcathc building or improvement is sold within one Year of completion, the
owner -builder will have the burden of proving that he did not build or improve for put,
Paseaf We.), ,
7
�,�� Z
.TOT
T
I, as owner of the property, em exclusively contracting with licensed Co..,.. to
convect be project (Sec. I0d4, Business and Professions Cade:) The Contracmes Li-
'
censelawdoesnot apply to an owner ofpropeny who builds or improves thercun,and
QTY. PLUMBINGP R E
who contracts for such prapm s with a contmnods) licensed pursued, to the Carbonates
PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec. , B & P C for this ..a
ALTER -DRAIN&VENT - WA (PA)
Owner Date
p VAI:UATION
Y'a
. WORKER'S COMPENSATION DECLARADON
RACK FLOW PROTECT. DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
DRAINS-FLOORROOF,AREA. CDND.
] I have and will maintain o Cenificam of Consent to self -insure for Workers Compen-
ration, as provided for by Samson 3]fI0 of the Labor Code, for the performance of the
S�BIIIES' YPECONSTRUCTION
V -
71haveawork for nd ill maintain Issued.
❑ 1 have end will Insurance, required by Section
Worker's Compensationce
PI%'TUNES - PEN TRAP
hl hV
ode, lot ofthw which
]yWorhe Lubapenation I Insurance cancer athe work (numbram permit is issued.'
My Workers Compensation Insurance carrier old Policy number ere:
Cartier. Policy No.:
GAS - EA. SYSTEM- I INCA OUTLETS
` C.O O APN
i
GAS - EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF IOLIMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no, M completed ifthepermlt is for one hundred dollen (SIM)
or less.)
GREASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IELS
GREASE TRAP
PLANCHECK FEB
I rectify that in me performance ofthe work forwhich this Permit is issued, l shall
no, employ any p .a in any.loner ao os m become subject to the Workers Comped-
SEWER -SANITARY -STORM HA. 2W FT.
ENERGY FEE
WATER HEATER WNENWELECTR
sation Laws of California. Dam
Applicant -
GRADING FEE
NOTICE TO APPLICANT. IL after making this Cemificate of Exemption, you should
became subject to the Workers Compensation Provisions of Ne Labor Code, You must
WATER SYSTEM/IREADNG
SOILS FEE
forthwith comply with such Provisions or this permit shall be domed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
' Ihereby affirm that is a convection lending agency to; the performance of
NEW RESIDENTIAL PLMB. SQ. FT.
PAID
Dote 6pta
the work far which this permit is issued (Sec. 3091. Civ. C.)
Lenders Name
TOTAL:
Landers Address
TOTAL:
BUILDTNE
1 certify that I have read ,his application and state that the above subornation is
QTY, MECHANICAL PERMIT FEE
SEISMIC FE .
correct. l agree m comply with all city and county ordinances and same laws relating to
building convection, and hereby authorize representatives of this city better sn
er up ,he
PERMIT ISSUANCE
ELECTRIC FEE
above-mentioned property for inspection purposes..
(We) agree to save, indemnify and keep handless the City of Cupertino against
liabilities,judgments, costsand expenses which may in any way memo against said City
in consequence of the gmn,ing of this permit.
ALTER OR ADD TO MECH.
PLUMBING FEE IF
'
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON -POINT
SO RCEREOU A ONS.
AIR HANDLING UNIT (OVER 10,000 CPM)
TI
CONSTRUCON TAX
a
a
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
gntureo t nr Date
HAZARDOUS MATERIAL. CLOS
-
HEATING UNIT (TO IW.WO RTU)
WiliNenpplicomorfuwrthuildingoccupams,ore mandle haiallous material
t
as defined by the Cupenino Municipal Gale, Chapter 9,1 d the Health and Safe,y
Code. Section 2553200?' .
HEATING UNIT' (OVER IBD,000 BTL))
❑Yes . , ❑No
'
Will the applicant or future building necupam use equipment or devices which
It hazardous air conwminums ns defined by the Bay Arca Air Quality Management
isWctl
❑Yes Otho '
PAID
VENTILATION PAN (SINGLE RGSID)
Dam Receip,p
BOILER - COMP OHP OR 100,W0 BTU)
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have read the havardons materials requirements undo Chapmr6.95 ofte Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
tomo Health & Safety Code. Sections 25505.25531 and 25574.1 understand that if the
buildingdoea nm cumen ly have a tenant, that i, is my tesponsiblity to notify the occupant
of lm requirements which must he tet prior to announce of a Certificate of Oxupanty.
ISSUED BY:
TOTAL:
Owner or authorized agent - Date
OFFICE
,r
BAY AREA AIR QUALITY
MANAGEMENT DIST T�
939 ELLIS STREET /fD�
••••� SAN FRANCISCO, CALIFORNIA 941 /C/fJw OM/p
(415)771-6000 t% /S
Sep x (� G 19, 1995
�psp 1g9S
Ferma Corporation C16oq0#00,
1265 Montecito #200
Mountain view, CA 94043
ACKNOWLEDGEMENT
J# 18177
Bay Area Air Quality Management District acknowledges receipt of your Asbestos Demolition/
Renovation Plan described as: Demolition
site address 19500 Calle De Barclna St
Cupertino, CA 95014
start date Aug 31, 1995
completion date Sep 29, 1995
removal amounts 0 linear ft. 0 square ft. friable acm
Should it become necessary to revise this plan, please do so in the spaces provided below and
immediately send a copy to the District by fax or by mail. Do not revise notifications which are,:.
exempt or for which you have not yet received acknowledgement.
ASBESTOS
NOTIFICATION REVISION
BAAQMD J# 18177
revision #
start date`
completion date
i// i
fel'
removal amounts
lin. ft. sq. ft.
2 —/—/—
—/—/-
3
4
5
lin. ft. sq. ft.
lin. ft. sq. ft.
lin. ft. sq. ft.
lin. ft. sq. ft.
NOTE: This form Is not intended as a verification of either the completeness of your original
notification or of its compliance with District Regulation 11-2 .
N