21100APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALLPOINT PEN ONLY
Building Project Identification
Building Address:
l `> 300 �TZ✓cNs CR��
PERMIT NO.
f� al 1 O O
G I I
wnera N= one:
GO (�6-
T Co ra rr',Name: Lk. No:
IA A R•'j LS, I a /i
CITY OF CUPERTINO- BUILDINGDIVISION
APPLICATION / PERMIT
BUILD INGELECTRICALPLUMBINGMECHANICAL
CATEGORY
CONTROL#
Arch) act /Engineer. F Lk. No:
q'IV
ELECTRICPERMIT
FEE
BUILDING PERMIT INFO
(� p pp-l�//,�ss 1- , r, q /�j p,
Addnss:'I t gOx CONT�6 *DEsL lsl GO (/
PERMITISSUANCE
.(� D
❑ ❑
LICENSED
LICF.NSF:D CONTRACTOR'S DECLARATION
ATI
I hereby affirm that l am bcensed under provisions of Chapter 9(commm
ingwith Section7000)of Divlsion3ofthe Busineaand ProteesionsCode,and my
license is inf orceypd N(jOn.
Llcenaes OYS Tc.N 29 5 �
Date to -0- ontractar ��ea✓s
ARCHITECTS DECLARATION �'��'
]ur Taad, v 1, aBbeuse aspubII,:mmMw
Licensed P— rofeWonnaar
OWNER - BUILDER DECLARATION
1 hereby afOrenthat I am exempt from the Contractor's License Law for the
fo0owing reason. (Section 7 031.5, Business and Pro@alons Code: Any city or
county which requires a permit to mmtmo, alter, impmve, demolish, or repalr
anystmcturs pdorto its WUanee,aho requirmtheappllrant forauch permit to
file a signed statement that he Is licensed pursuant to the provblons of the
Contractor's License Law (Chapter 9(mmnlencing with Seaton 7000) of Dlvi.
sion 3 of the Business and Professions Code) orthat he h exempt thamfmm and
the basis for the alleged exemption. Any violation of Section 70115 by any
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollar ($.500).
I, as owner of the property, or my employees with wages as their sole
compensation, willdothe work and theshucture is not Intended or offered for
sale (Sec. 7044, Business and Profemions Code: The Contradoes Lim. Law
does not apply to an owner of propertywho Wilds or Improves thereon , and
who does such work himself or through his own employees, provided that such
Improvements are not Intended oroffered formle. If, however, thebuilding or
Improvemontbsold withinoneyearofmmplaton,the owner- butklawlllhave
t rden of proving that he did not build or Improve for purpose of s ale.).
L as owner of the property, am exclusively contracting with licensed
contractors to censtruct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improve thereon, and who contracts for such pRo" with a
��0(Tactor(s) licensed pursuant to the Contncie 's Llmna Law.
c�JI am exempt under Sec. B k P C for this mount
APPLIANCESRESIDENTIAL
— JOB DESCRIPTION
^
r rs
S Vll
PANELS
201.1000 AMPS
OVERIODOAMPS
-
SQ. FT. 11,011M ARFA
$ /SQ, FT.
SIGNSELEGTRICAL
SPECIAL CIRCUIT /MISC
TEMP. METER OR TOLE INST.
POWER DEVICES
'
SWIrIMINC POOL ELECTRIC
OUTLE3SSWITCHESR%TURES
VALUATION
NEW RESIDENTIAL ELECTR
STO
TYPE CONSTRUCTION
Qiy,
TOTAL'
PLUMBINGPERMIT
.�
FEE
CGItOl1P
RIS. UNITS
PERMIT ISSUANCE
�q.pg -DRAIN kVENT- WATER ffA)
FLOO
APN
BAIX FLOW PROTECT D
. EVICE
FEE SUMMARY
DRAINS FLOG ROOF,
R, RI'�4 COND.
FIXTURES. PER TRAP
SANITARY Y_ N_
RECEIPT if
Owner Date -
WORKMAN COMPENSATION DECLARATION
1 hereby affirm that I have a mrtiBcate of consent to self - Insure, or a
en fiateofWorkere'Comper tionlw nnmoracenifledmpythemof(See.
3800, L b
PoRq _ 9t a 4? 3 4-.
SCHOOL FAX Y_ N_
RECENT #
GAS EA. SYSTEM-1 INCA OUTLETS
PARK FETE Y N
RECEIPT N
CAS EA. SYS I'FAt- OVER 6(PA)
Co�mpa '�S�LIs--
�/SiY'IQ� 1'I i
BUILDING DIVISION FEES
VlCertlt� copy is hereby fumlehed. �—
MCeniRed mpy h filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Rhls sedlon need not be complMed If the permit is !canons hundred dollar
($100)orlead
I llnot that o4, any arson i any manner so as to b co eesubjec Issued,
1 shall not employ any person in any manner m e to become subject to the
Workers' Compensation Laws of California. Date
NOTICE
NOTICE TO APPLICANT: tothe, aftermakingpa ation Pro isons oft the
you subjecttothe Work era' such pruasonprovhlonsofthe Lab or
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there isa co nswMlon lending agenry for the penormry
ance of the work for which thin permit is bored (Sec. 3097, Clv, CJ
Lender's Name
Lenders Addma
I mnifythat I have read this appllationand statethattheabove information
Ismrrect. I agree to complywith all cityand countyordlnanes and orate laws
relating to W Ilding construction, and hereby authorise representatives of this
city to enter upon the above- mentioned property for Wptabon purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against llablBtles,judgments,cosm.tuf expenseswhkh mayinanywayaccroe
agairet mid City In consequence of the granting of this permit.
GRASE/INOUSIRL WASTE INTERCEPTOR
PLANGHECI4, FEE
PAID
Date Racei t#
GREASE TRAP
SEWER-SANITARY-STORM EA. 200n.
WATER HEATER W /VENT /ELECTR
ENERGY FEE Y N
PAID
Date Recei t#
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
TOTAL:
UUILDING •E •
TOTAL:
SEISMIC FEE.
ELECTRIC FEE
a N1
a y
-/%
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO I0p00 CEM)
-
Date RB eipt#
SUBTOTAL:
�-
AIR HANDLING UNIT (OVER 10,000 GEM)
CONSTRUCTION TAX
Signature of Applicant /Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Cade�+. -S�ection 25532(a)I
❑ Yes L_I No '
Will the applicant or future building occupant use equipment or devices
which emit hazardous airmntamdnants asdetined bythe Bay Area Air
QaalltyMansgem entDhtrict7
4Yes ❑ No
M1ave is Heetazarzloety Code, terials
the Seatonremenh5533 and of
erstsd h Health build Code, Sea tons have 33and, that I
respontanlitytoflhfytheonupantooterequicments which b bey
responsibility of aCeheic to of Ocupancqulrcmentawhlch musibemmad
prior to Issuance of a Certificate of Occupancy.
EXHAUST HOOD(W /DI/CT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date Recei I#
HEATING UNIT (OVER 100,000 BTU)
TOTAL•
VENHLARONPAN(SLNGLERESID)
ISSUANCE DATE
pn� -
PA0 -
OCT n 1990
`AM F YTa7{J-
01 atcu�NV _
N`,Y
ISSUED BA A%% af4,1/
BOILER -COMP 'OR 100,000 BTU)
I
BORER- COMP(OV ]R 100,000M)
NEW RESIDENTIAL SQ.PT.
Owner or authonznd agent Date
TOTAL:
OFFICE COPY
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F Q g
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c,
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
(95,60 �- z✓�N.s CR�� 1tL
PERMIT NO.
21100
Owner's ame: one:
. n
/�t�-�x p g
CITY
OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDING - ELECTRICAL - PLUMBING- MECHANICAL
A A A
� �
Cc tra ors Name: QLic.No:
!J / / zo
CATEGORY
CONTROL #
Architect /Engineer. Lic. No:
�
, - ELECTRIC PtRRMTl'
BUILDING PERMIT INFO
11 l /' q �j Q
Address: ?I D , Cox �" � *T4 (k g_?" b
PERMITISSUANCE
�(� O
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commenc-
ing with Section 7000) of Division 3 of the Business and Professions Code, and my
license is in force�gd �qct. 7Y74..
License Cla G T3 is # 2
Date IO ontractor * '� ws
S%�
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
t q
( V Il
PANELS
201 -1000 AMPS
ARCHITECTS DECLARATION %nJ C ,
ndi��' n all be used
I u public records.
OVER 1000 AMPS
SQ. FT. FL R AREA
$ /SQ. FT.
SIGNS ELECTRICAL
0. V
�.`
Licensed Profe oral
SPECIAL CIRCUIT /MISC
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, alter, improve, demolish, or repair
anystructure priortoits issuance, also requires the applicant for such permitto
file a signed statement that he Is licensed pursuant to the provisions of the
POWER DEVICES
Contractors License Law (Chapter 9 (commencing with Section 7000) of Divi-
sion 3 of the Business and Professions Cote) orthat he is exempt therefrom and
VALUATION
OUTLETS-SWITCHES-FIXTURES
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
%j
a !/
NEW RESIDENTIAL ELECTR
five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole
STORMS-
TYPE CONSTRUCTION
compensation, will dothe work, and the structure is not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License Law
TOTAL
does not apply to an owner of property who builds or improves thereon, and
who does such work himself or through his own employees, provided that such
improvements are not intended or offered for sale. If, however, the building or
C GROUP
RES. UNITS
improvement issold within one yearofcompletion,the owner - builderwill have
the burden of proving that he did not build or improve for purpose of sale.).
L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
;am
PLUMBING PERMIT
FEE
FLOG
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts for such pgojects with a
contractor(s) licensed pursuant to the Contractor's License Law,
E] I am exempt under Sec. B & P C for this reason
ALTER-DRAIN &VENT - WATER (EA)
PEE SUMMARY `-
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS - FLOOR, ROOF, AREA, COND.
SANITARY Y_ N_
RECE 7F #
Owner Date
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self - insure, or a g.rdficate
of Workers Compensation Insurance or a certified copy thereof (Sec.
3800, Lab jj�
Policy iiL OS" '� .
FIXTURES- [JRES PER TRAP
SCHOOL TAX Y _ N
RECEIPT N
GAS EA. SYSTEM -1 INC.4OUTLETS
PARK FEE Y_ N_
RECEIPT #
GAS EA. SYSTEM -OVER 4 (EA)
cc_mpanv 77Z1�1� 1 %
BUILDING DIVISION FEES
1Certifiie y is hereby furnished. �—
M Certified copy is filed with the city inspection division.
GREASE /INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
j, j
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
/ 7
GREASE TRAP
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars
Date Recei t#
SEWER-SANITARY-STORM EA. 20017T.
WATER HEATER W /VENT / ELECTR
ENERGY FEE Y N
($100) or less.)
I certify that in the performance of the work for which this permit is issued,
WATER SYSTEM /TREATING
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
Applicant
Date Recej t#
NEW RESIDENTIAL PLMB. SQ.FT.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
TOTAL:
should become subject to the Workers Compensation provisions of the Labor
BUILDING FEE
. d
Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform,
ance of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information
is correct. I egree to comply with all city and county ordinances and state laws
SEISMIC FEE
O
TOTAL:
ELECTRIC FEE
_ ('
PLUMBING FEE
QTY.
MECHANICAL PERMIT"
FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above- mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may in any way accrue
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL
B- 3
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION ,TAX
Signature of Applicant /Contractor Date
EXHAUST HOOD (W /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12,• and the
Health and Safety Code Section 25532(a)?
I] Yes NN.
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Q
BOILER -COMP (3HP OR 100,000 BTU)
Quality Management District?
❑ Yes MN.
■
BOILER -COMP (OVER 100,000 BTU)
I have read the bazardous materials requirements under Chapter 6.95 of
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
t+t { tl 1�` {�('1
t r 2 ! 990
NEW RESIDENTIAL MECH. SQ.FT.
understand that if the 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 of Occupancy.
�
411 o cup "110
�
ISSUED BYJ IA\A1 WV C4-,t �
Owner or authorized agent Date
TOTAL:
F
OFFICE COPY