20292APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pm'c<t Identification
Building Address:
PERMIT NO.
/1 ^ /� n
10 �s r s Re it/ -
G O 292
wnare sine:aiLiU "f�iip �ona
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
_ _ A
C°nnctor'sname: Liciyca"°.
BUILDINGE.ECnUCAI.PLUMBING- I HANICAL
CATEGORY
CONTROL N
Arehltea/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: fO
PFRMITISSUANCE /�,VJ
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afit=that l am Bernard under provisions of Chapter 9(commenc
ingwlthSection7000)ofDiA,ion3ofthe Buslnessand Profevi.n,C e,amdmy
license is In full force and effect.
LicenseClam Zontr
Date Contractor
APPLIANCE-RESIDEN'ML
PANELS
]OBDESCRIPTION
701-1WO AMPS
ARCHITECI`S DECLARATION
I understand my plain shall be used as public records.
!rr
OVER IOW AMPS
SQ. FT. FLOOR AREA
$/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER-RUILDER DECLARATION'
I hereby affirm that I sin exempt from the Contractors License Law for the
following rcason.(Section 7031.5, Business and Professions Code: Any city or
cmntywhich mquires a permit toconatmcL alter, improve, demolish, orrepair
anystmcturc prlorm its issuance, aiso uxquireathe appBcan[fonuch permit to
file a signed statement that he b licensed pursuant to the provisions Of the
Contractor's License Law (Chapter 9 (no.scing with Section 70M) of Dlvl-
sion3ofthe Business and Professions Code) orthat he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70X5 by any
applicant for a permit subj is m
the applicant to a civil penalty of not ore than
fve hundred dollars ($500).✓t
I as owner ofthe property, or my employees with wages as their sole
e mpensation,willdo the work and the structure isnot intended Or offered for
sale (Sec 7034, Business and Prefeasiond Code: The Contracu,ex License Taw
does not apply to an owner of property who builds or improve thereon, and
who d°essuch work himself or through hisown employees, provided that such
i
iY
t,
in
SPECIALC1RCUfT/MISC Taro
TEMP. METEROR POLE INSf.
POWER DEVICES
SWIMMING POOL ELECTRIC
[� VALUATION
FP
•a
OUTLETSSWIICHESH%TURES . 00
NEW RFSIDENTIALELECIR SQ.FT.
�STOIU[S
7YI'E CONSTRUCTION
C
OCC GROUT'
RFS, UNTI5
improvements are not intended or offered for sale. If, however, the building or
improvement bsold within one ycarofcompletion, the owner -build erwill have
the*nJon of proving that hedid not build or Improve for purpose ofsale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Soc. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
bu
Wilds or Improves thereon, and who contracts for such pcujecs with a
TO L: '• �. SV
QTY, r PLUMBING PER I FEE-----
PERMIT I55UAN
AL3FR-DAMN & - p
U55DzoN
pPN
oO,attn,ctor(s icemcd pursuant to the Contractors License Law.
LII am empt\ nd� ^ B k P C for this mason
a
BACK FLOW PRO T. D CE
FEE SUMMARY
Owner I—S
�
WO AN COMPENSATION DECLAR O
❑I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Inaomere, mea codified copy thereof (Sec,
MOO, Ib C.)
if
DRAINS R F,ARE&CIOND.
SANITARY Y_ N —
RECEIPT It
FIXTURES 7A Tex
SCHOOL TAX Y N
RECEIPT N
GAS E.A. SYSTEM-11th .40UTLETS
PARK FEE Y NPol_
It
Cram any
❑P Certified copy b herebyturnbhed.
❑Certified ropy b (Tied :vith the city Inspection division. ,
GAS FA. SYSTEM-OVER4 LEA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDI�NC DI VISION FEES
PLANCHECKFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsectitnneed net be<omplow lfthe permit isforone hundred dollars
WWI me l„t.)
lanot emptor anypfore, inan theworkmanner forwhwast beco permitctto the
I shall not employ any person in any manner at u to become subject to the
W an Compensation lawn of Gllfomld. Date
Applicant
PAID
Date RC'cei t#
SEWER-SANITARY-STORME,. HAFT.
WATERHEATER W/VENT/0-ECTR
ENERGY FEE Y N
PAID
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.__SQ.f•7,
NOTICE TO
come. bICANT':I(Worl making this
sationluteof Exemption,you
Labor
.houlCude, become subjecttothe Workers'such prsatl°nprovbis permit
Code, you swat forthwith comply with such provblona orthb permit shall be
d`xcefd rev°ted
co"srgurno s LENDING AGENCY
Ihercbya(flrmthauhere bacomwctlon lending for perform
arcs of the work for which this permit la issued (Sec. 3097, Civ. C.)
Lender's Name
Lender'sAddress
I certifythatl have mad thsapplication and etatethatthe above infomation
bcorrect. Idgere tocomplywith all cityand county ordinances and state laws
tO building construction, and hereby authorize reprearetativn of this
citytoenterupon the above-mentioned property for Wpection pu rpmae.
(We) a to save, indemnify an d keep harmless the City of Cupertino
against IBtles,ydgmen[s,cases and expenses which may In anywayamrue
ag na a dCity cone sof th anting of this permit.
<
Dale ReCei t#
TOTAL:
BUILDING FEE
TOTAL:
SEISMIC FEE
FEE
ELE!ICAL
,
QTY. MECHANICAL PER FEE
PERMIT ISSUANCE z_�a
PLUG FEE
MECFEE
`O
FEESrelating
-
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO ]0,000 CFM)
RCCCIFt#
SUBTOTAL:
AIRHANDUNG UNIT (OVER 10,t10OCFM)
CONSTRUCTIONTAX
S na o(Applicant/Comcacior—� Date
HATARDOUSMA ERIALSDISCLOSURE
IXHAUST HOOD(W/DI1CT) �',
CONSTRUCTION TAX PAID:
HEATING UNIT (TO ]W,00007L0
Will theappllcant or future building occupant store or handle haealloua
fin
material as deed by the Cupertino Municipal Code, Chapter 9.12, and the
Ilealth and Safety Code Section7553I(a)7
EDyesN No
Wlilthe applicant°r home, building occupant use equipment°rdevices
which emit hazardous air contaminanb as defined by the Bay Area Air
Quality Management Dis a7
4ye�°
Date RCCCi I#
HEATING UNIT (OVER IW,000 BTU)
TOTAL:
DD
VFNILATIONFAN(SINGLE REBID)
ISSUANCE DATE
p
PAID
BOILFR{OMP 0HPOR IW,WO BTU)
havercad the hazy sreateeiab requiremonts under Chapter 6.95 of
the California Health A Safety Code, Sections 7550.5, 25573 and 25534. 1
understand that lfthe building does not currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of0ttvpanry.
MAY 1 5 1990
Cit!/ of r!in,irtipo
BOILER-COMP(OVER 100,000 BN)
NEW RESIDENTIAL MFCH. SQ.FL
�
ISSUEDBY: ��4, v C,(�x
Owner or authorized agent Date
TOTAL:
OFFICE COPY P