20188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project tdentlfleatmn I PEIt ITN'O.
Building Address: 20188
21050 McCLELLAN ROAD
A A A
FOOTHILL DEANZA COMM. COLLEGE CITY OF CUPERTINO-BUILDING DIVISION � O .Q
:.road.,',Name: Lie.No: APPLICATION /PERMIT l
ROMA CONSTRUCTION BUILDING-ELECTRICALPnUMBING-MECHANICAL CATEGORY CONTROL.
Architect/Engineer. Lic.No:
DAVID TAKAMOTO ASSOC. 'Qif ELEC_f_R[C PERMIT `. . FEE ' BUILDING PERMIT INFO i
Address: PERVITISSUANCE ❑ lk' ❑ ElLICENSED GONTRAROR'S DECLARATION
I hereby
eaffirm that Bconsedt underprovisions of C9(commenc APPLIANCES.REEDENTIAL
708 DSAlI'f10N
ingwthSccdon70 )ofDivalon3oftheBusasaand Pro(nssionsCodn,
and my PANELS
limnseisio (o deffect
LlmmuA;1a dLle.I 488329 `�
Date antra`-.—FAARrS� CT. /
ARCHITECT'S DECLARATION IDI-1000AMPS
HOZ I understand my plan shall be used as public records. OVER t000 AMT'S LJjaIQW AR EAi 5/�.FT.
_ O
_ ofZ 5 Licensed Professional SIGNS ELECTRICAL
j OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MIX P
Ihereby affirm that l am exempt from the Contractor's License law for the CMI
UT OR
following reason.(Section 70315,Business and professions Code:Any city or TEMP.METER OR POLE INST. /
countywhich requires a permit tocovtruct,alter,Improve,derohsh,or repair
lv< anystrucure pdmtaiut ame,aUonquimtheappBcantforsuch permitto TOWER DACES
.=O file a signed statement that he Is licensed pursuant to the powlalons of the
KC_t. Contractors License law(Chapter 9(commencing with Section 7000)of DIA- SWIMMING IDOL E.ECTRIC VALUATION
305 son3 ofthe Businm and ProfmlonsCode)orthat he B exempt thenfromand
the baafa for the alleged exemption. Any violation of Section 70315 by any 12 OU7LETSSWITCHESFIXTURFS ..�
_�_m
applicant fora permit subjects theapplicant to a civil penalty of nu more than
five hundred dollara(S.5001. NEW RESIDENTIAL ELEC[R SQ.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
mmpmsmion,w0l do the work and thestracture B not intended or offend for
O vie(Sec.7066,Business and Pmfmiont Code:The Contractor.Llmme Law
does notapplytomownerofpropertywho builds or Improves thermM1 and OCC.GROUP RES.UNITS
who doessuchwork himxlforthmugh hlsownemployces,provided thatsud, y/
impmver nUs mtlntendedorofferedformle.Khowevegthebuildinge, TOTAL C .fes
bnpmvement8a Id Mthinoneyearofcompietlon,theowner-buRderwlllbve
thAmrden of proving that he did not baud or unprove for purpose of sale). QTY. :PLUM131&G'PERMIT- '..FEE HpOD MNE APN
[a owner of the property,am exdusvely contracting with licensed PERMIT LSSUANCE
contncton to coatrott the project(Sm 7066,Business ami Profmbns Code:
The Contnctofs Lic ae Taw does not apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such pippcos with a );'; FEE _
m ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE - ' 'SUMMARY��'
u I am exempt under Sec B&P C for this reason -
•
OUTSIDEFIES
DRAINS-FLOOKROOF,AREA,COND. SANITARY Y_ N_
wOner Date RECEIPT a
E31 hereWORKMAN COMPENSATION DECLARATION FD(TURFTRAYPER TRSCHOOL TAX Y_ N_
by affirm that I have a certificate of consent to selfdnsure,ora RECEIPT a
cmifiam of Worker'Compensation humans or a cero(W copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N-
31 3lab C.7 CC RECEIPT
Po11ryM GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com any 11 HH1L,
�CenuiN mpybhereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CcrtNed copy V flied with the city W pecilon divlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANHARY-SCORM EA.200FT. Date Remi (#
(This section need not be completed If the perma isforom hundred dollar
(5100)ar ler3 WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_ -
I cmifythat Nthe performance of thework for winch thio permit la Laved,
I shall not employ any person In any manner m as to become abject to the WATER SYST[M/TREATING PAID
Workers'Compensation Laws of California.Date
0 Z Applicant NEW AESIDCNT[AL PLMB. SQFT. Date Remi t#
Z O NOTICETO APPLICANT-.If,after madding this Certificate of Exemption,you
should became eubject to the Worker'Compensation provuiom of the Labor TOTAL:
t—
NCode,you res at forthwith comply with such providoaorthis permit shall be BUILDING FE
dmrred revoked.
W 5; coNsrxumoN LENDING AGENCY SEISMIC FEE
(L I hereby affirmthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z ance ofthe work for which this permit is issued(Sec.3097,Civ.C.I PLUMBING FEE
() O T<nder'a Name Qjy, MECHANICALtPERMIT'�" FEE
LL 1— Lander.Addres. MECHANICAL FEE
w
1 mNlythat l have read this appliati....d samth t the above Information
O FEES PAID
bommet.Lgrm to comply with all city and county ordinances and sate laws PERMIT ISSUANCE
y 6. relating to building coatructlon,and hereby authorize representatives ofthis
N at to entero the above-mentioned property for ion ALTERORADDTOMECH.
F- Z y pun l Petry pest purposes. Date Receipt#
(We)agree m save,Indemnify an d keep ,which the City of a Perth. AR HANDLING UNIT(TO 10,000CFM)
V agaiatllab' tles,jadgmenb,cosaand rases which may in any way accrue SUBTOTAL:
.gaiat ity m Goa t ,rung of thea permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER to,aoocHd)
3-18-91 CONSTRUCTION TAX PAID:
Signature o(Appdmnt/Contr Date IXIiAU5T fI00D(W/DUCT)
111=0 ATE IALS DISCLOSURE HEATING UNIT BTU)
Will the applicant or Future building oceapant store or handle hazardous _ Date Recei t#
material as defired by the Cupertino Municipal Code,Chapter 9.12,and the
Heakh and Safety Cade Section 25532(a)i HATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes �]Na VENTILATIONFAN(SINGLERESID) ISSUANCE DATE
Will the appliant ass forum building omvpant use oqulpment or devices
which emit havrdous air mntaManrndcfined bythe Bay Area AU 80TLFR{OMP pEI'DR 100,lXq BTU)
Quality M.agement District?
4Yee ❑❑No
h.ve readtheh.z.rclous materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) lid
the GlEfemla Health&SafetyCode,Sections 25505,25533 and 25536.1 hTW RFSIDENIIAL MECII. SQFT. L
understand that if the building does not currently have,tenant,that it Lamy I,AR 2 t
the nyu.iremenr which must berM 1591
pmutoissumccofaCertifictc,fOccmpnry
� Owner or authorised agent Date TOT,\L: ISSUED BY: a
OFFICE COPY