30810 APPLICANTTO FILL'IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO„. ” _ "BUILDING-ELECTRICAL ` PERMI'(NQ.- ;/.�1
BUILDING DIVISION APPLICATION/PERMIT •.PLUMBING'-MECHANICAL" 3 V 81 O
_
BUILDING PROJECT IDENTIFICATION
1 B ILDING ADDRESS: - ' SANITARY NO. APPLICATION SUBMITTAL DATA
lg �•N • -2
„ BR'S NAMG: PHONE. + NTRACTOR S•NAME' _ LIC NO: _
,dal NIC -CONTROL.
RCHI E /EN�E R. LIC NO: . A�OSS: 0 ❑ •`k. .
CONTACT:
PHONE, - BUILDING PERMIT INFO
. '•h A7,j'L✓S O Zl '{ •LL�/[' ❑ ConsultanVFe or Paid by Applicant(Initial), "BLDG, ELECT PLUMB MECH-
r l l ✓Z T
❑ ❑
LICENSED I a CONTRACTORS DECLARATION hap QTY ELECTRIC PERMIT FEE
1 h by fr don I fc d stir and
fsC pt 9(commencing JOB' CRIP,TION
{io{in�a z 'cone surammo) fD 3 fthe 9uslne.ana pmreaa an Cod a l '
F�0 mPollf -ntl effect -.n ytce avis' PERMIT ISSUANCE ''• >. .
%UV License Class Lia.. _ ❑SFDWL ❑KITCHEN REMODEL.
n6a Da¢ _ Comracmr APPLIANCES-RESIDENTIAL ❑AD N Ll PLUMBING RE-PIPE,
[.7y ARCHITECT'SDECLARATION PANELS 0 TI-UNIT El STRUCTURAL
.Z p I understand my plans shall be tiled as public accoNs . - MODIFICATION
OZ-, UP'10200 AMPS - INTERIOR
O CHIMNEY REPAIR,
�4E"u] Licensed Professional 201-10(g)AMPS IMPROVEMENT
ppp .
OWNER-BUILDERexemptDE Ce CmilbON OVER IWO AMPS ❑BATH REMODEIIREPAIR'O DEMOLITION
Q I hereby affirm Nm I am exempt Tmm the Cmntmctor'e License Law for the
L��S t1 U fallowing reason(Section 91)31.5,Bromeva and Professions Code:Any city circuitry SIGNS ELECTRICAL- ❑OTHER
a+W ya which requires aP 't to resonant,aIt improve,demolish r ref.ir any 'tmctr.
w.$
prim,to its1 qme the plicionri h permitt rile a signed statement SPECIAL CIRCUIT/MISC.
P+ that he is licensed pursurint tothe provisions mateContractor s License Law(Chapter 9
(commenting with Section 701 of Division 3 offine Business and Professions Code)., TEMP.ME Him OR POLE I T. - +COMM R IA
S ea that hes exempt[hent t and the basis f the it g d iorranplion.Any violation of -
W[;N Section 90315 byanyappIm7dI far.permit,doca,duappllcvnto.vial penultyof POWER DEVICES ❑NEW INT ADDITION. -Q DEMOLITION'
not m thanF hundred d llars($500), ❑TENANT "• +(]FOOD SERVICE
C ❑1, s fth p pnyb ye ply ❑ ages as the 1 p at n, SWIMMING POOIMPROVEMENT
will do thework,and th t t intended r ff ifar I (S 9044 Business ❑OTHER
ad Pmfiaxaorw Code The C t a t r. License Law does n t apply to an o[ OUTLETS-SWITW-FIYURES
R'3 property who builds improves all a ct who does such workhimself or through {a r e
his own employees,provided that such improvements are net intended or offered for _ NEW RESIDE IALEL/ R SQ IT Ir
sale.if,however,the building or improvement is sold within one year ofcmmpletion,the SQ.FT.FLOOR AREA $/SQ.FT.
owneobuilder will have the burden of proving that he did not build or improve for pur�
pose mf salmJ.
E] I,a.owner of the,Nay,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.7044.Business and Professions Code:)The Contmctur s Li-
cense Law does not apply toanowneiofproperty who builds or improves thereon,and QKj UMBING PERMIT ' FEE _
who contracts forsuch papects with a contractous)licensed pursuant to the Contractors
License Law. MI .SUANCP,
I •• +
I am exempt under Sec. ,B&P C for this tarso
Owner Date IN&VENT-WATER(EA) •, VALUATION '
WORKER'S COMPENSATION DECLARATION
I hereby offimt under penoltyof peju,one of the following declamtio _ _ 1(T.�fi
I have and will maintain a Carificatemf Conwrl to self-insure for Worker' tJ �REA,COND.
.,atlon,as provided for by Section 3700 of the Labor Code,for the Eaton. t - STORIES TYPE CONSTRUCTION
work for which this permit is issued. C CQ
I have and will maintain Workers Compensation Insurance,as required by Section o
3]04 of the Labor Codn fnrthe performance ofthe work for'which this permit is issued. f - NC.OD rnaCC OCC.GROUP - APN
My Worker's C"we ti Int ace carrier and Policy u a O y s OVER C �II a ete '
Cartier: Policy Nm.:
"
CERTIFICATE FROM WORKERS' L1p�
COMPENSATIONINSURANCE CO LWV'f`
(Trois section need not be completed ifthe prirnu is formic hundred doll, ,(.I) r _ . BUILDING DIVISION FEES
or lass.)
_ • I olythat'ntheperf eofthPLANCHECK FEEaw kf hich thi pe tis�s. d,ishell ,
SEWER
Q oempl y tryp min y n'ast h ompSANITA ENERGY FEBZ tionLdw' fC If
Data
' Q TSRH TL WQU CTR
Applicant - - GRADING FEE
h �s
NOTICE TO APPLICANT If,after making g th C i T ate f F y should WATER SYS'T77
F�
become subject to hetW k r Comps s ti p r f the L b Cotl you must SOILS FEE
Lt: 2 forthwiths comply with such punaane or this permit shall be de dked. RVICF
M
CONSTRUCTION LENDING AGENCY
t�)Z+ - NEW RESIDENTIAL B. PAID
-
TherebyaffirmthvM1 isacnnumaionlending agent rth puri rinancem
.- Ne work for which this permit is issued(Sec.309],Civ.CJ I 3 .•ti
Lenders Name .TOTAL: -
O W Lender's Address 'I - p
�ytr ly I certify that 1 hav ed this application and smte m the above information is BUILDING FEE
tr V] coir,[ lagmem comply th 11 ly nd county ordm see,d cc ll tngto QTy. MBCFIAMCAL PERMIT- PEE
LJ,7. buJdmg wmvwetimn,and ho¢hy authorise represenmi •s mf Olds city to enter upon the. SEISMICFEE
above-mentimned property for inspection purposes.
' (We)agree m save,ioLamnify and keep h esa the City of Cupertino against PERMIT ISSUANCE ELECTRIC PEE
liabilihesqudgmems.call., d p les which ma n any way accm,against said City ALTER OR ADD IO MECH.
in consequanoe of the gra nng'Rh permit. PLUMBING FEE +
APPLICANT UNDERSTANDS AND WILL MPLY WITH ALL NON-POINTAIRHANDLING UNIT('CO 10,000 CFM) ,SOURCE SOURCE REGU NS. MECHANICALiTT
erI
AIR HANDLING UNIT(OVER 10.000 CPM)
� � —Z T'� CONSTRUCTIONTAX
Signatureof Ap icanuCnnw'to' - Dare EXHAUST HOOD OMMUCT7 HOUSINGMU'IGATIONPEE-
"' an OUS MAT IALS DISCLOSURE• - _
Will the applicant or Pomre bulldi occupant area or handle huzardous material HEATING UNIT HT)100,000 BTU)_ -
as defined by the Cupertino Municipal de,Chapter 9.12,and the Health and Safety -
Code,Section 25532(x)?. .x HEATING UNIT(OVER 100,000 BTU) -
❑Yes ON.-
VENTILATION
._ VENTILATION FAN(SINGLE RESID) PAID '
Will the eppllenm or furore ilding occupant ave equipment or devices which' Date .,.Receipt M
emit hazardous air conmminnme defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,010 BTU) -
District'1. TOTAL:
❑Yes. F]No BOILER--COMP(OVER 100,DIDBTU)
'AIR CONDITIONER s _
'I'h dtho h,sallousmatenals ray t ndeCh pt 695 fNe Gh- ISSUANCE DATE
forma Health&Safety Code,Seamus 25505 25533 and 25534 1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building d tot currently have a tenant,that uls my responsibiWy to notify Ne timpani
afthe requirements which must be met priors ante of a Cemfcate of Occupancy
t
Owner or authnmed agent - Otte TOTAL: ISSUED BY:
OFFICE i'
Inspection Query for a Specfic Permit 4/7/97
0810 10899 IDE ANZA IFOUNDATION 2/3/97 CC 2 P
0810 10899 DE ANZA FOOTINGS/REBAR 2/3/97 CC 2P
0810 10899 DE ANZA ROOF 2/3/97 CC 1 P
0810 10899 DE ANZA ROOF 2/4/97 214/97 CC 3 P
0810 10899 DE ANZA ROOF-FRAME? 2/5/97 CC
0810 10899 DE ANZA REBAR/BLK WALL 2/7/97 2/7/97 AD 2 P
0810 10899 DE ANZA BLOCK 3RD LIFT 2/10/97 TO 2 P
0810 10899 DE ANZA REBAR 2ND 2/7/97 217197JB 3 F
0810 10899 DE ANZA FRAMING 2/13/97 2/13/97 JB 1F
0810 10899 DE ANZA INSULATION 2/13/97 2/13/97 JB 2F
0810 10899 DE ANZA FRAME 2/14/97 2il4/97 CC 1 P
0810 10899 DE ANZA INSUL 2/14/97 2/14/976C 1P