20936APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pooet Identification
enu\ Address: pis �
, 12 Co , s�or!- 53 b9
PERMITNO.
20936
wne a Nante: one:
S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGELDCTRICALPLUMBINGMWHAMCAL
AP 0
S—�YI 0
Contactors Name: LIr. Nn:
17TOM,
CATEGORY
CONTROL X
Architect/Engineer. Lic. No:
Jl
Qn ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
3 \1_ \\1_- y A
Address: Z 'P Vf DOa� RK' S
,ate
1 /( ❑ ❑ ❑
I I
PERFRT[SSUANCE
LICENSED CONTRDECLARATION
Ihereaffirm that lamgcrosaunder] nsolp r9(m
h edion7000)o(Divlstm3oftheBudmmandPro(mionCodeandm
11...binfu d
Gm — LIc.X
Dale Contactor In
ARCHITECTS DECLARATION I
I underala nd my plane shag be used as public records.
Lirnnsed Professional
OWNER -BUILDER DECLARATION
I herebyaffi mthat I am exempt fromthe Contractors License law fm the
following reason. eertion 7031.5, Business and Professions Code: Any city or
cmnlywhichmqubesaper twmme ct,mter,bnprove,dem it h,orrepalr
anystruen re priurto its isntance, also requlrntheapplicant fmsuch permit to
file a signed statement that he is licensed pursuant to the provlatom of the
ContndorsLicense Law (Chapler9(mnromcmg with Section 7000) of Divi-
s1on3 ofthe Business and Profeadmci Code)orthat he le exemptihere(romand\\
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectstheapplicant tea civil penalty of nomore than
five hundred dollar (5.500).
1-11, am owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure G not Intended or offered for
sale (Sec 7014, Business and Pro(ee.lom Code: The Contractor. Llnms Law
does not apply to An owner of property who Wilds or fmpravn thereon.and
who does suchwork himself orthmxagh his own employees, provided that such`
improvements are norIntended or offered for male. If, however, the building m
Improvementis sold within one yearo(completion, the owner -W ilderw111 Favi
tl)Lkurdenof proving that he did rot build or Improve for purpose ofsale.) I
u L as owner of the Property, am exclusively contracting with llmmend
contndors to mmtrud the project (See 7014, Business and Profeselom Cade:
The Contractors License Law don not apply to an owner of property who
'Wilds or Improves thereon, and who contracts (m such p(ojects with aTER
��ll((acmr(s)licensed punuanttothe C..b.emr's Llrense Law.
LJ I am exempt under Sec. B A P C for th
APPEANCESRESIDENML
JOB DESCRIPTION
17_�
W
PANELS
UP TO 2DOAMPS
201I000AMN
OVER IOD AMPS
SQ. Fr. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCUIT/hiISC
TEMP. MEIERORPOLEINS.
POWER DEVICES -
SWIMMINGPOPIELECHUC I -
OUTLETS-SWI SHXTUREq
VALUATION
bt o3,/
L
NEW RESIDENII ECTA r"Q'ET'
STORIES
TYPE CONSTRUCTION
TOTAL:
QTy, PL B PERM] FEE
OCC. GROUP
RES. UNTfS
FLOOD ZONE
APN
IT ISSII
ALTER -DRAIN & VFM- A
FEE SUMMARY
BACK FLOW OTFL. C
I. P, CO
SANITARY Y_ N_
RECEIPT X
Owner Date
WORKMAN COMPENSATION DECLARATION
MI hereby affirm that 1 have A cartiirate of cunxnt m self.insom, or
cartiflcale of Workers' Compensation lnsummm or a certified ropy thereof(Sx.
3800, lab C.I
Policy X -
ADRAI
SCHOOL TAX Y_ N_
RECmPI' X
-1 INC 60UTLE15
PARK FEE Y N
RECEExT X
—
GAS EA. SY -OVER 4 (EA)
Com any
BUILDING DIVISION FEES
FCetlOed copy is herebyte
�Certltled copy is filed withh the cityIn+petbn division.
ty
CERTIFICATE OF EX,EM PITON FROM WORK ERS'
COMPENSATION INSURANCE,
(This section need nee be completed If the permit is for one hundred dollars
01m)or leas.)
'mob'
m b'Iy he M he performanceofthewmk(orwhic Me ermitb issued,
I shall not em o any peso n any manner Anobject to the
Workers Com n tion Tat o allfomia. Data
AppEcant
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Rami t#
I GREASETRAP
SEWER-SANITARY-STl7RM F.A. 20014T.
WATER HEATER W/VENT/Ft FCTR
ENERGY FEE Y N
PAID
Date Reeel t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SOFT.
NOTICE TOM ICA ';ILA ser staking, b CimBfcxteef Exemption, you
should become eubpd to re Cmepereallon provlalomofthe Labor
Code, you moat forthwith comply with such provisions orthis permltshall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afRen that thereis a mmmudion lending agency for the perform
arm of the work for which this perrtdt b Weed (sec. 3097, Civ. C.)
Lander. Name
L.nd.r.Address
I certify that] have read this applicationand statethatlheabove information
is corred.lagree to emnplywlth all dtyand mxmtyordlnanaaand mate laws
relating tobullding eorslmdion, and hereby authorize representatives of thio
city to enter upon the above,mentiosed property (or inspection purposes.
(We) agree to save, IndemNa harmlethe City of Cu per
fy an d keep, ss iro
against liabilities, judgments, costs and expenses which may in any way accrue
against said City In consequence of the granting of this permit.
'
TOTAL:
-
U DN G FEE
SEISMIC FEE
TOTAL.
ELECTRIC FEE
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date Reeei t#
AIR HANDLING UNIT (TO 10,000 GEM)
SUBTOTAL:
AIR HANDENG UNIT (OVER IO,00)GEM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will theappgcant or future building acrupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter9.IZ and the
I fealth and Safety Cade Section 75537(a)I
F1 Yes
Will the applicant m building occupant use equipment m device.
which emit hazardous a contaminants as de fin ed by the Bay Area Air
Quality Management Mct7
RIYn o
hy,emad the haza oterfalsrequiremanutunder Chapter 6.95of
the CA llfomla Health fety Code, Section 75505, 25533 and 25534. I
on a nd that if the building does not currently have. tenant, that It la my
res one Illty to notify the occupant of the requirements which moat be mat
'prl t nuance of rtifkata of Occupancy.
nerorautho sed en DIV
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
HEATING UNIT (OVER I W,= BTU)
TOTAL:
VFNIILATION FAN (SINGLE RESID)
ISSUANCE DATE
w.
PaD
�J a 1990
tea k 4s
"
aa.�-
w
ISSUED B�Y�:q {Xa/�+�U'r wYl� u"••^--ekl
BOILER -COMP OF I' OR 100,000 BTU)
BOILER-COMP(OVEt100,000BTU)
NEW RESIDENTIAL MECIL SQ.FL
TOTAL:
.a OFFICE COPY