23132APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
1 9ndding Address: b -- gra-T�s P H Ac, :C-
_ PFRMITNO.
23132
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CITY OF CUPERTINO-BUILDING DIVISIONsName:
APPLICATION / PERMITBLRLDINGELECTRICALPLUMBINGMECHAMCAL
APPI1CAIIbNSUBMII1,kL A ,
LIc.N.
r—Archited/Engincer.
CATEGORY
CONTROL #
Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: -
PERMITISSUANCE c �—
a[ rat ❑
IBJ
LICENSED CONTRACTOR'S DECLARATION
IMreby a(llrnthat lam licensed under provisions of Chapter9 (commenc
Inensei inforces Divfect. (she Bualneuand ProfeulonaCnde,and my
limner. Is in full force and affect.
APPLIANCES -RESIDENTIAL
P
]OB 'TION
R�
License Class LIc.M
f
Data Contractor
UHT
ARCHITECPS DECLARATION
I understand my plans shall be used as public records
20
O 000 AMPS
SQ. FT. FLOOR AREA 5/SQ. FT./�
Licensed Professional
SIGNS ELECTRICAL
3yft
OWNEReBUILDER DECLARATION
I hereby affirm that [ass exempt fromthe Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
aunlywMch requlmapeuNttocomtrotl,altth applicant
any atrumrm statement
Issuance,hheIs also reed pursuant
t to then fowisio permit e
file a signed statement that het licensed pursuant to the pro7000) of the
Contractor's ofthe Business Taw(Chapter9(comrpndng with Section7000)Divi-
ion ebasis for
Business and Professions AnyCode)viothat lation f Section 7MI.5 by and
the scan for the alleged exemption. Any violation of penalty o nor m by any
applicantfOra permit$500). the applicant toadull pensity of not more than
five .odiewnerdollars ofthe p0).
as owner o(the property, or my employees with wages act their sole
co pe ation,wBldu the work and the structure is non intended or offered for
(Sec 70K Business and Prefessbns Code: The Cmuradols License Law
✓((,,JJ
CMCJ M g
r
SPECLILCERCUIT/
TEMP. M OR POLE INST.
DEVICES
%VIMMING POOL ELECTRIC
V—ALU aA710N
I�
(�E.ISSW(,rcI-�SHXITJIZES 2
NEW RESIDENTIAL ELECTR SOFT'
STORIES TYPECONSTRUCTION
`� n �`
L • t_ CC I "
m
snot apply to an owner of property who builds or improver. thereon,and
who does such work himself or through hisown employees, provided that such
forsale. IfhoweverthebulldingorTImprovement issold withinoneyearofcomplMiogtheowner-WBderwill haveen
- i _�
OCC!GftOS1P "1,WS
i O°J.I � tlimprovemcntaarenotintendedoroffered
of proving that hedid nabuildorimprove forpurposeofsale.).
owner of the property, am exclusively contracting with licensed
on to construct the projM (Sec. 7014, Business and Professions Code:
QTY, PLUMBING PERMITpLOOpa
PERMIT ISSUANCE
Contractor's License Law does not apply to an owner of property who12
Wilda or Improves M thereaand who contmda for such p(oj no, with a
[,p5!Iactor(s) Bcensed pursuant to Me Contractor's License Law.
LJ I am exempt under Sec. B & P C for this reason
ALTER DRAIN & VENT WATER a:nn)
te
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mctifiate of <onunt m self-inarre, mr a
certificateof Workm'Com .tionInsuranceoracedifiact copythamof(Sec.
3800, Lab C.)
Policy #
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N
RMS p
FD(77)RES PER TRAP /
SCHOOLTAX
RECEIPT
GAS EA. EM -1 INCA OUTLETS
PARK FEE Y N
RECEPT X
Co say
r5Cssrtifled copy V hereby furnished.
❑ Certified copy E filed with the city impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS•
COMPENSATION INSURANCE
Uhissectlonneed notbecomplat d lithe Forma isforone hundred dollars
(5100)oryssd
!certify (hatoythe say ersonI sa thewark f.an as tochthis pesubjec to the
I shall not employ any person In any manner eo u to become subject to the
ApplleWorker%Compensatlon laws of California. Date
NOTIC rat
NOTICETO APPLICANT: If, nuking thio CertBlate of Exemption, you
shoull on eabpct tothe Workemi Compensatton provisions ofthe Labor
deemed umustfmrthwith comply withsuch provisions orthb permit shall be
deemed revoked.
GAS EA. SYSTEM -OVER 4(FA)
_
GREASE/INDUMRL WASTE INTERCEPTOR
BUILDING DIVISION FIiES
PLANCHECKFEE 4 C
PAID 1 I�J
Date Remi t#
GREASETRAP
SEVER -SANITARY -STORM EA. SFT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N '
—
PAID
Date Reeel t#
WA.IIR SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT.
IOTA
UI NG •-E
CONSTRUCTION LENDING AGENCY
Iberebyafflrmthat there is a construction lending agency forthe perform
anco of the work for which this permit Is txsoed (Sec. 3097, Civ. C.)L<ndets Name
Iandcre Addmaa
I rrrtlfythat 1 have read Ills a..Rotbnandatnethatthov
eabeI ,Uor i
T '
!SSEISMIC FEE
LECTRIC FEE
LUMBING FEE /•
QTY. MECHANICAL PER MIT FEE
MECHANICAL FEE
incomed. I agree to comply with all city and county ordlnancer. and state lawn
relating to bu lld Ing construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Wpection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu portion
against liabilities, pdgments, costs and expenses which may In any way accrue
p cof``th-e�� ingoltMspermit.
PERMIT ISSUANCE
FEES PAID:
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UNITE (To 10,000 CFM)
SUBTOTAL:
AIRHANDLINGUNIT(OVERIQ0D0CFM)
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
I���—
�OZ.of�Appl�nt/Contrracurrate
OUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,000 BTU)
-
Will the applicant orfuture building occupant store or lundle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Health Y and Safety Gds, Section 25537(a)1
Wllltheapplicant or❑future building occupant use equipment ordevices
which emit hazardous air contaminants., nt
deed by the Bay Area Air
Quality Management District?
4Yea ❑ No
havcmadthehazarvfouamaterialsrequirementsunder Chapter 6.95of
the California I lealth&Safety Code, Sections 75505,25533 and 25534.,
res orstand that ifmilefiyton notifhe y ing doesOccupant not currently equire entve atenanp that It r'9 my
respomibility to naity the oaupant of requirements which rust be met
prior to Issuance of a Certificate of Occupancy.
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
IOTA
VENTILATION FAN (SINGLE RESIDE
1$$ Any10E.DATE
• P�
04 I Y
1
AN p2 190,. ,..,
C17Y Ur LUfrt i l
BOR.FR-COMP QHPOR 100,000 BTU)
BOILER-COMP(OVER 10),000 BTU)
N'EW RESIDENTIAL MECH. SQ.Fr
^_
BYI
Owner or authorired agent DateISSUED
TOTAL:
OFFICE COPY
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April 17, 1992 IOS3 0 , k�Tn S
TO WHOM IT MAY CONCERN:
In return for early inspection and approval of the exterior
lath work on the bedroom addition at 10530 East Estates Drive,
Cupertino, California, the undersigned agree and warrant that all
dry -wall installed in said addition shall be affixed with screws.
Absolutely no nails shall be used in installing the drywall.
I
Dated: 1"-_20
/J P/ TH WS B. WEBER, Owner
o
Dated: Unr!
ROD JOD , Carpenter
Dated:
4
1
JERRY BRAGER, Inspector,
City of Cupertino