20684APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
-Building Project Identification
Bmlafgnedree>0 e emu GRe--eeic 01-v _
PERMIT NO.
- 20684
net. a one:
es'+U�CL2j'a4l 91t �.9
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION If PERMIT
BUILDING.ELECTRICAGPLUMBINC-MECI IAMCAL
c °�•"•°c° Li= "oy,
a -+-en i4� �•'0 5, ���at •� 7 3S 3 / �
C.,�pa�TG( RY /I
tan --y t Q f
CONTROI. N
Architect/ gl"'a K Llc. No:
C IT - �E at /f5? oc'
Q1Y ELECTRICPERMIT FEE
' BUILD)NG PERMIT INFO
tJ y" 4,9
PERMIT ISSUANCE
❑ 1:1K1 I ❑
C\
LICENSE CO TRACTOR'S DECLARATION
T hthSyion7OOOatlamRcen,ed under ftbeBuprovisldPrefession.9de,and c
of Dlvlelan3ofthe Busine&aand ProleuloneCode, and my
ingwe is In
license Is In full f rm qna affect. p
License Cla�7f LieM 4 !3(S /
Date ? - 7 f J Contractor s, cons ,
ARC CI'S DECLARATION t
I dents my a Mused p bile records.
LidnardP oolorul
OWNER -BUILDER DECLARATION
I hereby afBrmthatI am exempt from the Contractor's License Law for the
following reason.(Section 70D5, Business and Profession, Code: Any city or
mi
county which exquiresa pert tomnstruct, alter, Improve, derrolbh,orrepalr
anystructure, priorto lbissuance,&be requtreathe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the proNaions of the
Contream'e License faw(Chapter9(mmmencingwith Section 7000).! Divi-
g..3 of the Buai°eae and Pm(emloru Code) orthat he b exempt therefromand
tMWsIs for the alleged exemption. Any violation of Stolon 7031.5 by any
applicant for a permit subjecothe applicant to a civil penalty of not more Iban
five hundred doltzn(S50U1. '
Fj1, as owner of the property, or my employee, with wages a, their sale
compensation, will do the work and the structure is not intended or offered for
gale (Sec. 7044, Business and Pmfenums, Code: The Contractors License law
does not apply to an owner of property who builds or improve& t herm°,and
who dce,suchwork himself orNrough hisown employees, provided thatsach
Improvements am not Intended oroffered forsale. If, however, thebuilding or
impmvement issofd withinoneyearofcrmpletion,the owner-buOderw111luve
thC.JEarden of proving that he did not build or Improve for purpose of sale.).
L as owner of the property, am exclusively contracting with licensed
contracmm to coruuuct the project (Sec. 7044, Businem and Professlmn Cade:
The Contractors Li... Law does na apply to an owner of property who
Wilda or Improves thereon, and who contracts for such pkejeab with a
cge(Tactor(s)Ilmn.ed puntanttothe Contranor'•Limnse Law.
LI I am exempt under Sec. B k P C for this reason
APPLIANCESRESIDENfIAl
JOB DLSCRI'i10N
/f p��= Mo "A
R�j�oq L"� Z—M1/
.EPIC SrH� .5 n/F, T
PANELS �
201-IODO AMPS
OVERIOWAMPS
SQ. .FLOOR AREA N/SQ. FT.
_e pp��-.. N_�
I'rn ''+ 11 ry �I
ff 1:...' D If
�i II iI � II I E R
u— �J
ATIO
'----- -
SIGNSELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP METER OR POLE INST.
pOlygg DEVICES t//
SWIMMING POOL ELECTRIC TE
OUTLETSSWITCHIESFIXCURFS -
NEW RESIDENTIAL ELECTR SQ.FP.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY.' PLUMBING PERMIT FEE.
OCC.GROMI
RFS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN kVENT- WATER (EA)
FLOOD ZONE MINE
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
S DRAINS. FLOOR, ROOF, AREA, COND. 0-Vd
2Y FIXTURES PER TRAP OD
T
SANITARY Y_ N_
RECEIPT
Owner Date
WORK MAN COMPENSATION DECLARATION
I here !firm that I have a cemOcete of consentto selLlnevre, ora
mrtlfIr.bC) orken'Compewatlonlvurana ora mni0ed mpythenof(Sec.
Polis Lab C.)
SCHOOLTAX Y N_
��, N
GAS EA. SYSTEM -1 INCAOUILETS
PARK FEE Y_ N_
N
CAS EA. SYSTEM -OVER 4 (FA)
Com�an Y
DING DI
BUILDING DIVISION FEES
n CertinN copy is herebyfurnished.the city
�Certif ed copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thos section need not M complcted if the permit V !.core hundred dollars
(8]I0)arfy thworkat
(certify that o the pert°nrnIn any manner
so as to become
permitsubject
I shall not employ any person f any manner m u to become subject to the
to the
W plicae Cwnpensatlan laws of California. Date
Applicant this
NOTICE TOA, subject tote after makingper etttifloteis Exemption, you
shouldbecome subject thenply wi gtchprwtlon ,nflu, refit. Lab or
Code, you must (octhwltF comply with such provhlom or this permit shall M
ammrea revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirmthat hem is. construction lendingagency for the performTOTAL:
ane, of the work for which this permit Is Issued (Sec. 3097, Civ. Q
Leaders Name
Lenders Address
IcertifythatIhavereadthb viapplicetionand&atethattheab nformation
comma[. IagreetacomplywithalIctyand county ordinances and state laws
relating to building ronstruclion, and hereby authorize representatives of this
city to enter u Pon the above.mentloned property for inspection purposes.
(We) agree to save, Ind cmNfy an d keep hamum the City of Cu pertfno
against liabilities, to dgme E barde.pereaswhichmaymitaymy.ccme
agai Bald Cit in a ofthegrantinga(thiepennnit.
/- 9-9V
SI mature App i snt/Contractor / Data
HAZARDOUS MATERIALS DISCLOSURE
Wil hei ppileant orfuturebullding occupant storeorhandle hazardous
material as defined by the Cupertino Mumdcipa l Code, Chapter 9.1 2, and the
Health and Safety Code Section 25532(a)7
RYea No
ill the applicant Amre building occupant use equ 1pment or devices
which emit haze rdous air contaminants as defined by the Bay Area Air
Quality Management Dart&?
4 Yes �I No
have read test ouy Codc,abre.ca 25Sntsunder Chapter 6.95 of
the California Health k Safety Code, Sectlore 75505, 23533 and 25534. I
understand that if the building dues not currently have a tenant, that it is my
responslI�tytoactifythe ant of the requirementa which must be mat
of the requirement. which must be me&
-prior van fi i to fO.P:rcy.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recd tN
GREASE TRAP
SEINER -STORM -STORM BA 2WRI.
/ WATER HEATER W/VENT/ELF-CTR -
ENERCYFEE Y N —
PAID
Date Remi tN
WATER SYSTEM/TREATING
NEWRMDENTIALPLMB, SQ.FT.
TOTAL:
BUILE21NG FEE
��
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
.Df
MECHANICAL FEE
PERMITLSSUANCE
FEES PAID:
ALTFRORADDIOMMH.
AIR HANDLING UNIT (TO 10,000 CPM)
Date Recei tR
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
E HAus'I HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
Date Recef til
HEATING UNIT (OVER 100,000 BTX)
.—P
TOTAL:
VENTILATION FAN( SINGLE RES(D)
ISM DATE
L+�
JUL D 91990
p��ra xass{{((,sss��m�.��aa��::..a&a,�a
PirN at 4aa4ata}�Tg1�
ISSUED OY:`y= m
BOILER -COMP PFI' OR 100,000 THE,
BOILE2COMP(OVIiR 100,000 BTU)
NEW RESIDENTIAL MECH. S,.I7.
Owner or odzed agent Date
'
-
TOTAL:
OFFICE COPY