20473;PLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pru"err Identification -
Building Address
0 W Es -M -r S
PERMITNO.
20473
cu
V 1{S&3ST&3
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-ELECTRICA4PLUMBING-MECH LAICAL
s - Z
Conlractor.N.me Lie. N.
Archite t/Fsgineee Lk. No:
CATEGORY
CONTROL #
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
//'�'-7A.��d1
Address: 105-1 C
(,J r 0 0 .
j POWTIS5UANCE ZO(1
® � � ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provisions of Chapter9(commmc-
Se ton70W)of Asion3ofthe BuMmmand ProfessionsCode, and my,
license is In fun form and effect.
License Cbss Lk.#
Date Contractor
ARCHITECPS DECLARATION
I understand my plans shall In, used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contras is License Lawforthe
following re...(Scene.70115, Business and Professkns Code: Any city or
countywhichrequiresapermktomrutr Mager,improve,demolish,ormpalr
anyztmu mpdorloitsbsuance,alsorequimslheappBmntforsuchper tto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7") of Divi-
sloe 3 ofthe Business and Professions Code) orthat he is exempt therefrom and
the basis far the alleged exemption. Any violation of Section 70315 by any
pp permit subject, the applicant penalty of not more than
eve undred dollars ($500).
Q��I as owner of the property, or my employees with wages as their ante
cofnpensatlon, wlllelothe work andthe structure b not intended or offend for
sale (Sec. 70K Business and Professims, Code: The Contractors Llmnse Law
does not apply to an owner of pmperty who builds or improves Ihenron, and
who doessuchwork himself orthrough hbownempioyees, provided that such
Improvements are not intended oroffered for sale. If, however, the building or
Impmvementissold within.myearofcwnpletiogtheownerbullderw111 have
th,e�+rdenofproving that he did not build or improve for purpose ofsak.).
LJ L as owner of the pmperty, am exclusively contracting with licensed
contractors to cototruct the project (Sec. 7046, Business and Profession Code:
The Cont rectors License Law does not apply to an owner of property who
Wild. or Improves thereon, and who contracts for such p�ojecb with a
cc r,35L[acto licensed pursuant to the Contractor's License Law,
I -JI a empl under Sec. B k P C for this reason
APFOANCESRESIDENTIAL
PANELS
JOB DESCRIPTIONIngwilh
b 2QV'4 �i S
�Qf�ItTIJh ui•,� Z �r1OGtQ
7(11.1000 AMPS
OVER 1000 AMPS
SQ. FT. FLO OR AREA
S/SQ. FI.
SIGNSELECTRICAL
SPFGIALCII(CUIT/MISC
TEMP. ME7FdtOR POLE INST.
POWER DEVICES VI\ r
-
SWPSMING.POOL Q.0 RIC s
-
VALUATION
�(1 4
U (/�
0[TILETS TC}IFS _ _ l7�
NEW RESID LEL 'SQ FC.
SIOWES
TYI'ECONSTRUCTION
OCC. GROUP
RES. UNITS
T TAI VV
TY. PLUMBING PERMIT FEE
PERMIT ISSUANCE /
ENT- WATER (FA)
LTAOD ZDNW
ApN
BAGCT. DEVICE
FEE SUMMARY
OUTBID
Owner y D Z IA.I---
RI COMP SATIONDECLAR TIO IO�'�'r-RECEIPT#
QI hereby afflrrn that I have a eAnficate of consent to self -Inco, .r a
cert(fimteofWorkm'Comperuati-1--a orardifkdmpythemf(Sec.RECEIxF#
3800, Lab C.)
1'olhy #
OOF, AREA, COND.
SANITARY Y N
WFD(
SCHOOL TA% Y N
- CA 0UIL
-OV 6 IV
PARK FEE Y N
RECEFF#
m any
BUILDING DIVISION FEES
Certified copy Is hereby fumished.
eCaAifiedmpyl f11edwlththetltylnspealondivlsion.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
RMsseccio-toed notbec.mpleted lithe permit bforone hundred dollars
alm)or Ytha
cent that the Person ctissued,
J
1 shall not employ any person f any manner so es to become subject to the
an rammer forwNcheMs e, subjrmitect
Laws of Gllfornla.Date
Applicant
Applicant
NOTICETOAPPLICANT:I,aRer maWng fhb Ccrtlflcete o(Exemptlon, you
shwidbecomee 0, to the Worker?Compereatlon provisions ofthe Labor
Code, you rwat(arthwith comply with such provisions or this permit shallbe
dCen'od revoked.
CONSTRUCTION LENDING AGENCY
I herebyafRrmthat there is. comlmction kedingagency forthe perform-
ante ofthe work forwhich this permit is Issued (Sec. 3097,Clv.C.)
Lender's Name
Ianaer'iAahall
remingtobgreeto complywlthantltyand muntyordlnannsand gate
Irmotfyshallhave ready with allmtynand dcnate torelheabove dgat laws
relating m building comeroction, and hereby authorize representatives olthb
city to enter upon the above-mentlomd property for inspection purposes.
tove,indemNy an d keep harmiem the City of Cupertino
Dllab7ltexcx�l,
amenb,cos..rde.pemeswhichmaybi.eyway.ocrue
a dCRyin ryuenmof the granting of this permit.
�� S��/C^-
D
CREASE/INDUSTRL WA INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
GRFASETRAP
SEWFA-SANTT -STORM E.A.
WATER W/VENT/EL
ENERGY FEE Y N—
PAID
PAID
Date Revel t#
WATER STEM/TREATING
NEW DENTIAL I'LMB, SQ
TOTAL:
BUILDING FL'
- JD
TOTAL:
SEISMIC FEE
ELECTRIC FEE
I r -47
QTY. MECHANICAL PER FEE
ITISNANCE
AL ORADDTOMECH.
AIR HA LILAC UNIT(TO10,000CFM)
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
Date Receipt#a
SUBTOTAL:
AlR HAND cDnTr rovF�tfo,BoocFM
CONSTRUCTION TAX
�-
Sigmture of Appllcent/Contract ,V Ie
HAD RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material.,defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Safety code, Section 75537W)7
I❑l Yes
Will the applicant 0,hfuture building occupant use equipment or mit devices
which ehannious all contaminants a, defined Area by the Bay AAir
Quality Management District?
4haveYes. under P
niaHeath&SafLgyC delaectionremcnts5533..ha Chapter of
the Californiarnb health A Safety Code, Section 75505, ti533 and 75534. I
understand that if the building does lid wmatly have a tenant, that it Es my
mpomibility to notify the occupant of the requirements which Twat be met
prior to issaof
unce a Certificate of 0. P. nry.
EOIAUST HOO /Doer)
CONSTRUCTION TAX PAID:
HEATING UNIT (i0 ,000B
Date Reeel t#
HEATING
HEATING UNIT(OVER BTU)
TOTAL:
VENTILATION FAN `GL'RESID)
ISSI�QA ATE
MAY 2 91990
TS'*, O` Cap�tlrto
W. a7 [ V
1, r
ISSUED BY: W a seLV Lc -
BOILER -COMP NOR 100,0 TU)
OO LER- . P(OVPR•1W,000gTU
M1 ESIDENTIALMECH. .FT
Owner or authorhad agent Date
TOTAL:
OFFICE COPY
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