20850APPLICANT TO FILL IN IN WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification _ '
Balldl1
- PERMIT NO.
20850'
w rs erre ane:
-
• -
CITY OF CUPERTINO�BUILDING DIVISION
APPLICATION/ PERMIT
BUILDING-ELECTRICALPLUMBING-MECHANICAL
3%
a a - Lt.. N.:
CATFiGORY CONTRJdL��
BUILD! GPERMIT INFO
A /
101=
QTY , ELECTRICPERMIT FEE
Address: V• 1V4 3
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am Bcensedunder provlaloneafChapwr 9(rommen
-
APPLIANCES -RESIDENTIAL
JOB DESCRIDON
PANELS
ingwith&Mon 7000)ofD3Wslon3ofthe BusonemandProfeslonsCode,and my
license tsinfull rce nd effect.
License se Lic.M
Date Contractor 'S i mlR
ARCHITECIPSDECLAR TION
I understand my plans shall be used an public records.-
Licensed Professional - -
'
/y�)
'I DA/%- 7-0 �(P(�60r1�` l
207-1000 AMPS
OVERIODOAMPS ...
SQ. Fr. FLOOR AREA
n b O
$/SQ.FC.
"
SIGNSELECTRICAL -
SPECIALCIRCUIT/MPS
OWNER -BUILDER DECLARATION
I hereby afflrenthal l son exempt from the Contractor's License Law forthe
reaeon.(Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to mmtruct, alter, Improve, demollsh, or repair
% 4-1 t/following 4Y t4,w
c
TELAE MEPERORPOLEINST.
anystruentreprlortolfeissuance,alsorequimstheappllcantforsuchpermitto
file a signed statement that he is licensed pursuant to the provisions of the
Powu DEVICES
'
SWIMMING POOL ELECTRIC
` OUTLETS -SWITCHES FIXTURES
Contractor's Licerae Law (Chapter 9(commencing with Section 700D) of Divi-
Mon3 oflhe Business and ProfessionsCode) orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Sectors 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty of not rrerethan
VALUATION
, $6
NEW RESIDENTIAL ELECTR cS2�.
five hundred delta. ($500). - -
❑ I, as owner of the property, or my employees with wages as their sole
STORIES -
TYPE CONSTRUCTION
compensation, wllldotM work, andthestmcture b not Intended or offered or
sale (Sec 7044, Business and Pwf asoms Cade: The Contractor's Limns law
does not apply to an owner of property who builds or Improves thereon, and
who doessuchworkblmselforlhrough hisownemployees, provided thatsuch
'• OCC. GROUT'
RFS. UNITS
improvements are not Intended oroffered forests. Ithowevegthebulidlegor
TOTAL:
-
Improvementbwldwlthlnaneyearofcompldtb theoemer-Wflderwillave
tl)9,kurden of proving that he did not build or Improve for purpose ofsale.).
u I, as owner of the property, am exclusively contracting with licensed
contractorsm construct the project (Sec. 7044, Business, and Prafesakw, Code:
QjY, PLUMBING PERMIT FEE
FLOODZDNE
APN
- PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or improve thereon, and who contracts for such pTjects with a
cgNfaciora)licensed pursuant to the Contractors License Law.
u I am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT- WATER (EN
FEE SUMMARY°
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF, AREA; COND.
SANITARY RECEIPT M
Owner Data
WORKMAN COMPINSATIONDECLARATION
�ygylI hereby a((It that COMP a certticete of consent to self -Insure, ora
cdrtlRcateofWorkers'C a' axatlanlri 'ex eoracertlfiedcopy thereof (Se c.
3800,LabCJ'
I'oticy8
Cooany�7LQr�fSyLq
FD(T1RiES PER TRAP
SCHOOL TAX Y N
RECEI'r 8
GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y - N -
RECEIPT#
GAS F.A. SYSTEM-OVER4 MA)
BUILDING DIVISIONFEES
Certified copy is filed the city
❑ Certified copy b he, yfurnished inspection division.
CERTIFICATE OF E%EMFTION FROM WORKERS'
GREASE/INDUSTRL WASTE INTERCEPTOR -
PLANCH
�Xr, /j �'J
PAID tx -W/q� �7 ?—`" /TO
GREASE TRAP _
COMPENSATION INSURANCE
(Thlssectton need not be completed if the permit is forone hundred dollars
(5700) or lest.)
I certifythat o the performance ofthe work forwhich this permit is issued,
SEWER -SANITARY -STORM EA 200FT
�
Date Recei t# 7
WATER HEATER W/VENC/EL[CTA
ENERGY FEE Y N
SYSTEM/TREATING
I shall not empplen any person on any manner se as to become subject to theWorkWATER
et em loy any Laws of anycmla. Date
,�Ishan
PAIDApplicantNEW
i
RESIDENTIAL PLMB. -SQFT.
APPLICANT:!(,after making this Cemfloale of Exemption, you
became subject to the WorkeriCompensation pro1=of the Labor
Date ReceiNOTICETO
TOTA
.should
BUILDING
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked, -
CONSTRUCTION LENDING AGENCY
i
SEISMIC FEE
Ihereby afflrenthat there Is a construction lending agency forthe perform-
earn of the work for which this permit to Issued (&c. 3097, Civ. Q
Lender's Name
tander'snddree -- :
I certifythat I have read this application and state that the above information
I. correct. 7egreeto comply with all dyand county ordinances and elate laws
TOTAL:
ELECTRIC FEE'
PLUMBING FEE
QTY. MECHANICAL PERMIT 'FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building comtructlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purpose.
- (We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, pdgments,costsand expenses which may in anywayamue
Date Receipt#
ALTER OR ADD TO MECH:
AIR HANDLING UNIT(TO 10,000 CFM)
SUBTOTAL:
gainst..s%n eon ence of the- en ting ofthtspennit
AIR HANDLING UNIT rovER7D,000cFM)
CONSTRUCTION TAX
Slinature of AfElicam/Contractor Date
ECITALISTHOOD(W/DUC'D
CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CID 100,000 BTU)
-
Will the applicant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
HeslthandSafetyCodc ction 25532(a)7
'Date - Reeei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL: O
MYes a
Will the applicanto future building occupant use equipment or dcvices
which emit havrdous air contaminants as defined by the Bay Area Air
Qua lily Management Disme17
Rbavereadthehaz'- u6smaterlalsmqulrementsunderChapter6.95of
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE .
LAID
2'01990
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
the California Health&Ba(ety Code, Sections 75505,25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
AUG
1"1 u
NEWRFSIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met
priorlolssu ace rfa Certlflcateof Occupancy.
C-(� 0//7/70
rs n ..y4,�
city (if 4II1P4LSIh
ISSUEDBY: V lX^Y11'r"�'
ner or author) agent Date
TOTAL:
OFFICE COPY