24765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO )III ILDING-ELEC RI AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. � 24765
�4 �� C
BUILDING DIVISION BUILDING PROIECLTIDENTIFICATION J
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMH-I'AL DATE
10270 Imperial Avenue UNIT« 1 & 2 LOT It
OWNERS NAME: - PHONE: CONTRACTORS NAM17: LIC NO: NIC CON'I'ROLN
Clark Roa 08 257-3228 JOSEPH J. TAYLOR & ASSOC. INC.
. ARCIIITIICT/ENON10R: -LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY, F.LIiCTRIC PERMIT BUILDING PI7RMIT INFO
' pLyD ELF. L B 13
PERMIT ISSUANCE. 5`
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RP.S]DEN'I'IAL
JOB DESCR ON
qKZ IhcrcbyaRrm Harlem licensed under provisinnsafChepter9(rnmmrncing with a, p
EOO Svakm7d(10).f Uivi6m3.fthe Business rof ss Code,nndmy licensanim PANELS Pt,F,/hCj k.
UU fun foree and effect. -
r FZtL Licens C Lic. __ UPTO200AMPS 1../
Fay Date \Contiuv �' -11-1 AMPS V—U
Da
ZOvysL s ARCIIpGTCI-S -- OVF. Ilia) ti FT
SQ. .FLOOR A E, S/SQ.PI'.
OZ-0 I understand my pleas shall he used as public recards:
Ern W. S JN LEW,Fp...JJJ{ Licensed Bofuaninnal
���u DWNF.Rtl BUILDER DECLARATION ECL IRCGIT/ 1.
0yF 1 hereby afire that 1 am exempt from the Con.arl:',License Law for the
LL13Oma milawln,wit,on.(Section 7031.5,Business and Prnlcssions Code:Any city mcnunty
m J which requires a permit m conatmct,elter,improve,demolish,or repair any Iwcturc
E TA prior its issuance,also requires the applicant forsuch Permit to Illee signed nammcel I WER DIiVICIS
C p0 chat be is licnoad.....mt.the prnvieinns of the Cnmracmr'x Licatac Law(Chapter
wiao�' 9(cnmmencing with Section 78616 olDivisi�n 3nithe Business end Pmfcssions Code) SWIMMING PO(JI. LG IC /� VALUATIO?j.,
,,,� ar that he is exempt therefrom anJ the buil far the alleged exemption.Any violotion of 1 -S
LETSWITCHES'-FIXTURES
S
the
ZQ Section 7031.5 by any applicant for a permit subjects applicant to a civil penalty o[
not marc then five hundred dollen(5500).
❑ I,asowneroft'aeproperty,ormyemployecs with wagesanheinNEW RPSIDFNI'IAL ELECTR 5 'FT.olecnmpensurion, Q Ell[) ' nrr�or+sTRucDON
33 willAmhe work,and the ntrucmrci.anrnintendeJ.,offered fors:de(SecJ044Dusinesc F}
and Professions Code:'1he❑enactor's license Law does nal apply 1n an owner of �
property who builds.,improves thertaM1 and wh id.such work himselfaahmugh his
own noplayees,provided that such improvements are not intended militated forsnle.If, trb C. 'R IP RES.UNITS
however,the building or improvement is,sold within one year ofcomplefion,the owner- TOTAL: p p �5
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe pmpeny,amexdmivelyconbuaingwith licensed conmacmrstu QTY. PLUMBING PERMIT Li
construct the project(Sec.7044,Business and Professions Code:)The Comrvcmr's
License Lawdoes not apply to an ownerofproperty, PERMIT ISSUANCE whobuildsorimpmves thereon, �Jt)
who com rams for such projects with a contructor(s)licensed pursuentin the Cominwons AI'IER DRAIN FA
License law. ( ) ITESUMMARY
❑ I am exempt under Sec. ,n&PC for this moorBACK FLOW PROTECT',DEVICE FEES
IT
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RMi'll .
WORKMAN COMPF.NSA'I'ION DECLARATION SCHOOL TAX YN
I hereby ufirm that l have it certificate ofcoment to sclf-inampa,or a certificate of ' FIXTURES-PER TRAP RECIAPTN
rakes Compensation Imareaceoru certified copythereof(Sce.3900,Lab C.)which PARK FEE Y N
covers all employee's under this permit. RECEIPT 4
y PolicyN GAS-EA.SYSTC•M-I INC.40I1T1.[TS BUILDING DIVISION PEES
`81 Cert
icamyified copy is hereby famished GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE /I
• 1fy
❑ Cmifinl copy is tiled with the city inepeninn division. GREASI?JINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GFULAS69RAP SOILS FEE
COMPENSATION INSURANCE
(Husscetton neednot becomelewdiffheparoursfo...chiramoddollan(SHO) SEWER-SANITARY-STORM PA.2001"T. ENERGY FEE
or le".)
I eenifydne,in the Performance nfine work far which thio permit is is mel,I shelf WATER BEATER WNENH/F.LECI'R 5�
not employ any person in any munner en as to heroine subject to the WorkersPAID
Comicanciionlawsof Califomia. Date WATER SYSTEMfMEAI'ING Dote Receiptp
0 z Applicant f
z 0 NOTICE TO A PPLICANT:If.after making this Condit of Exemption,you should NEWRES]DFNTIALPIN B. SQ.FT. TOTAL: 357.10
P-• VJ became subject to the Workers Compensation pmvisiom of the Labor Code,you must
•`� ; forthwith comply with such provisions or ibis permit shall be deemed revoked BUILDING PER -QD
4t7 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE , b 3
z I hereby affirm that is a construction lending agency for the perfa rnamm of O
U O rhe work for which thio permit is moped(Set,3097,Civ.C.) TOTAL: ELECTRIC FEE - 15—
Lender's Name
OF Lender's Address QTY. MECHANICAL PERMIT PEIi PLUMBING Mr. 2Z SO
U I certify That I have read ilia application and state that the above information is
'� a correct. lagreemcamply with all city and county aminanccs and Imre laws misting PERMIT ISSUANCE �� C7 MECHANICAL PEE a2' 0
In building construction,and hereby auNoriu representatives of this city to enter upon the CONSTRUCTIONTAX
U Z .bove-mentioned pmPeny for inspection purposes. ALTER OR ADD TO MF.CII.
(We)agree to save,indemnify and kap harmless the City of Cupertino against
Iiabi lilies,judgments,costs and expenses which may in any way accrue against laid City AIR HANDLING UNIT(10 1 0,03d CFM)
to consequence of the granting man,permit.
i AIR HANDLING UNIT(OVER 10,000 CFM)
Sigowum of Applicant/Com actor
Data EXHAUST HOOD(W/DUCD r(j V PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.010 It Data Reccipi g
Willthe upplicam or fmure buildingoccupunt store or handle himadousmmerinl HEATING UNIT(OVER 1110,000 BTU) 'fOTAI.:' PO
as defined by the Cupertino Municipal Code,Chapter 9.12,and We Healh and Safety
Cade,S���yy 25532(a)7
cx El No VENTILATION PAN(SINGLE RESID)
(j{Y
rloWill the applicanmrfmurchuildingrccupant useequipmemmdeviceswhiehemit
tlO1LER-COMP(311P OR 200,00h JOU) ISSUANCE-DA'PC
herald minn
s air connnts as dcOned by the Be,Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
iFEBF18 1993
smict7
❑ WIN.o NEW RISIUEM'IAL MECH. SQ.FT.
I have read the ha>erdous marcrisis requirements under Chapter 6.95 of the Cf fY (jr vQf ILI s'a
California Health Safety ode.Statim.25505.25533 it 25534. 1 underamndthm
ifthe but g In not
eel atenan that it is my mievesdal try to notify the
wcup the equir cat It met prier m issuance of.Ccnilieme of ,
Dee
l cr orawbnriud agent Data TOTAL: 5 ISSUED BY:v Oe— /9Nr0t UCCI
OFFICE