20460 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add ma:
22295 Carta Blanca St. Cupertino 2046•x,
nera Name: one: -
2i hard SOhall CITY OF CUPERTINOBUILDING DIVISION O
contralto/awme: LIc.No: - APPLICATION I PERMIT 6/13/90'
'' Archttm/En neer. BUILDINGFI.HCTRICAL['LUMBINGMECIiAMCAL CATEGORY CONTROL# �� ,
Lm No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addred.1084 Saratoga-Sunnyvale Rd.
PERMIT ISSUANCE ,� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hthSyi-f 7000etlamIlemosen!under.i.3ofh.B..I uvla d sof Cssions9(rommrnc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
)I---hSection to.
flhe Bueinassand ProfeulonsCade,and my
Lt.. Is Ins fortx and dice#-. PANELS
Dcena cen Lie#--2_4_0_2 8_3Plumbin Re
Date orNattor CJ/ pipe '
ARCHITECue Plumb.-201-1000 AMM
fpw 0O Zp Iundemtand mypisru e)aB be used npubllc records. OVER 10!10 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
E�() Lkeneed Profemlorul SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION BpP.CUL CIRCUIT/MLSC
7O � lherebyaffirmthat lam exempt from the Contra tor's Lianee law for the
O Z.. following reason.(Section 7001S,Business and Profeniona Code:Any city or '
P s' rountywhkhmqulmapemr wmmtr d,aller,bnpro ,demolish,ormpair TT'Mp'METER OR POLE INST.
onysH mmpdortoltissuance,alsorequlrntheappgcentforsuchper tto
Me a signed statement that he In licensed pursuant to the pmvtimu of the POWER DEVICES
3 Conine[./s License lawtChmpmr9(comammeing with Section 7000)of Div,
k5 hercfmmand
VALUATIONS ion3oftheBudtaandProf—i- Coe)orthatheteam ttSWIMMING POOL EL
;� the bast far the alleged exemption. Any vlotatlon o(Settion 7fDt.5 by any OUTLETS-SWITCHES-FIXTURES
rr��S! appli�ant(ora permit subjects theapplicanttoe civil perultyotnotrromthat
p; flue hundred dollars($500). NEW RESIDENTIAL ELECTR
G01 I,as owner of the property,or my employees with wages as thele dole 54.FTSfOW LS TYPE CONSTRUCTION
rompensaHon,wllldolhe wakandthemncturc isnoHntended or offered for
O mid lSxc 7000,Bua1•...and Profeaioro Code The Contactors Lla.Law
$$ does notapply to an swear o(property who halide
n,and
whodonaucM warkhimeelathrough hlsownempleyen,prwMed thatsuch OCC.GROUP RFS.UNHS .
Improvement are not Intended oro((ercd fonale.]4 however,lhebuildingor :TOTAL: .
Improvement tmldwithlnone yxarofcomplellon,theowner-bullderwlllhave
tlurden o(pmving that he did net build orlmprove for purpose of ukJ. QTY. PLIJIVI$1NG PERMIT FE$ 1•T.00D ZONE 1
u I,see owner of the property,am exclusively mntraaing with licensed APN
rontractanto rorulnttthe pmjett(Sec.704y Buelnea and Prafeaioa Code: PERMIT ISSUANCE'
The Cnotatlors Liana Law don not apply to an owner of property who
Wild. or Improve thereon,and who mntram to,such pkujetta with a ALTER-DRAIN k VET-WATER(RA)
cgpl[actor(d)Bad pursuant to the Contnctods License Law. FEE SUMMARY
LJI nam exempt under Sec B A P C for this reason BACK FLOW PROTECT.DEVICE
Avner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT a
QI hereby afllrm that I have a certificate of consent to self-Insure,or a PTXT(IRES-PER TRAP 16 . 00 SCHOOL TAX� C.) RECEIPT M c certificate of Worken'Comperuation lruurana or a certified ropy themof(Sec.
MOD,Mab GAS PA. INC.4OUTLLTS PARK FEE Y N
Pdicy,a RECEIPT M
Cn������pppppaa�aany GAS EA.SYSTEM-OVER#(EA) BUILDING PT VISION FEES
I l certified copy is heed with the
cd
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ILR-M�'�.Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WORKERS'. CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANrfARYSIORM EA 200P1' Date RCCCI [N
(TMsaee.) need net hcompleted Iehe perMt t(orone hundred dollars
($1I0)afY that
WATER HFATERW/VENT/M TR' ENERGYFEE Y N
Icertlfy that Nlhe perfomunceof the work forwMch this permit is blued, —
I shall not employ any person In any runner an as to haeme subject to the
O Workers'Compensationlawsuf GB(omla.Date WATER SYSTEM/TREATING PAID
Applicant
Z 0 NOTICE TO APPLICAN.If,after making this C.M[I-m of Exemption,you NEW RESIDENTIAL PLMB.__SQ.ET, Date Revel t1f
Hshould become subject to the Warken'Ccrnperuallon provisions of the Labor
WW Code,you must forthwith comply with such provisions or this permit shall be TOTAL:
j deemed revoked. BUIL12INC FEE
(L a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there t a construction lending agency for the perform- q.
D Z ance of the work for which this permit is Wued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
L) 4 Lander'.Name_OO..e PLUMBING FEE
LL F 1<ndoe.Addroa QTY. MECHANICAL PERMIT 'FEE -t MECHANICAL FEE01
O W I ceraylhatl have mad thisappbationend sttethattheabove Information
6 tmrmet.I ugrceto comply with all city ami county ordinanasand Mete laws PERMIT ISSUANCE FEES PAID:
} W relating to building romtrvction,ind herebyauthorizerepresentativesofthis
F Z city to enter upon the abovcrrcntioned property for Inspection purposes. ALTER ORADDTOMECH.
— (We)agree to ave,andemnlfy an d keep harmlen the City of Cu Fenian Date Receipt#
agalwt liabilities,Judgments,ones and expenses which may In any way amus AIR HANDLING UNIT(to 10,000 CFM) SUBTOTAL
against amid City in cor"V f the granting of this pemdt. •
13_( -
/� � _9.0 AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sigatureo Om o recta R x( pate
HAZARDOUS MATERIALS DISCLOSURE IXHAUS'f TI
HOOD CON TAX PAID:
Will the applicant or futurebuildinggnicipan ode, hapten 9.hazardous HEATING DMT(T'0100,00)BTU) Date Reoei t#
nuteHdnd Safety by the Cupertino Municipal Code,Chapter 9.12,and the
IFFkmland Safety Code Section 75532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. UNG
Willthe applicant orfulumbuilding occupant useequlpment ordevlces VENTILATION FAN(SINGLE RESID) - 1$$O
which emR hazardous air contaminants as defined ANCE�ATE by the Bay Area Air ,AN
Quality Management District? BOILER-COMP GHP OR 100,000 BTU)
Yes No p
have read the hazardous materials regWoment under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) xJL .1 3 19J(]
the Callfomia HealthkSufety Code,SeOiov2SSOS,25533and25536• I V
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. .
rnponvlbllity to notify the occupant Of the requirements which..at be met
prior to Issuance of a Certificate of Occupancy. - else/ Qi Cupertino
Ow*Tor uthon a re ISSUED BY: Vl� •`� s
TOTAL:
OFFICE COPY