21012APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Bulletin Pro en Identification
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9 ven�Is c�Reelc wT
-�PL°IVMIT NO.
21012
Owner
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(A)e" Z4 a'e / OIPL S
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICA4PLUMBLNGMECFIAMCAL
,
D
Contractor's Name: sec. No:
N le0S e—OA S� 3 S 39
CATEGORY
CONTROL I
ArcM1ltect/Engineer. Lie. No:
QTY ELECTRIC PERMIT. FEE
BUILDING PERMIT,INFO
Address:
❑ . ❑
PERMITISSUANCE
LICENSED CONTRACFOR'S DECLARATION
Iherebyaffirm that l am licensed under provtsionn of Chapter 9(comment,
Ingwith Sectbn7000)of Divislon3 ofthe Beguessand Profned onsCodGand my
license Is In full to. and effect.
LicenseClassLIc.X
Date Contractor
ARCHITECTS DECLARATION
I understand my plans.hall be used u public records.
Licensed Professional
WNER-BUILDER DECLARATION
0I hereby affirm that I am exempt fromthe Comractofs License Law for the
following max°m(Section 7011.5, Business and Pro(eslons Code: Any city or
county which requires a permit to cotutrua, alter, improve, demolish,orrepair
anystructure prlorto its hoome e,alsorequires the applicant fee such perndr to
file a signed statement that he b licensed pursuant to the provisloru of the
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
sion3oflhe Budnese and Pro(emloru Code)orrhat he Vexempt there(romand
the bash for the alleged exemption. Any violation of Section 7m L5 by any
applicant for a permit subjects the applicant to a civil penalty of not morethan
five hundred dollars ($5(X0.
C] 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure is not intended or offered for
sale (Sec. 7064, Business and Profe®ime, Code: The Contractoes Limme Law
docs not apply to an owner of property who builds or improves thereoq and
Nsowneenployees, provided thatsuch
Improvements are not Intended oroffered for sale. If, however, thebuilding or
improvereenthsoldwithin oneyearofcomple foo,theowner-buRderwlll have
thgkurden of proving that M1e did not build or Improve for purpose of ole.).
Lf L as owner of the property, am exclusively contracting with licensed
contractors to ron5truct the project (Sec. 70K Business and Professions Code:
The Contractor's License law does sec apply to an owner of property who
Wilds or Improves thereon, and who contracts for such projects with a
cocreme) licensed pursuant to the Contractor's License Law.
LII am exempt under Sec. B A P C for this reasonOUTSIDEFF
APPUANCMIZESIDENFfAL
JOB DESCRBrITON
n
PANELS
201-1000 AMPS'
OVER1030AMPS
SQ. Fr. FLOOR AREA
'
\
\
5/SQ. FT.
SIGNSELECTRICAL r 1 n
SPI:C]ALCBtCU1T/MISC
TEMP METER OR POLE INST.
-C
POWER DEVICES
SWBshRNC POOL ELECTRIC
OUTLETS -SWITCHES ITXTURES
A An
NEW RESIDENTIAL ELECIR SQ'Fr'
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC.GROUP
RFS. UNTIE
PERMIT ISSUANCE
,lib
ALTER -DRAIN 8: VENT- WATER (EA)
FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES, PER TRAP
SANITARY Y N_
RECEITT 0
Owner Date
WORKMAN COMPENSATION DECLARATION-
E31 hereby affirm that I have a m tiflate of consent to self mixem, or a
certl(late o(Worken'Comperwtlon huurance ora artifled copythercof ($ec.
3800,abCJ
Policy
SCHOOLTAX Y_ N_0
AECOPr M
GAEA. SYSITINCA
Y N
TM
GAS EA. SYSTEM -OVER 4LEA)
CnMnY
BUILDING DIV ISION FEES
etlfied copy is heed with the
Certified copyb(Iled with the city Inspection division,
city
CERTIFICATE OF O(FMPTION FROM WORKERS'
COMPENSATION INSURANCE
Qhis section need not be completed If the permit V fmorx M1undred dollars
($100)orless.)
Icanot mployany penvenhat I. the In n lmimner forwhl becomh this esxbtec I. issued,
I shag set employ any person in any manner m u to become atbject to the
WorkerCompenation Gwa of California. Date
Applicant
NOTICE 110 APPLICANT: a after making for Certificate of Exemption, you
should oremus sforth forto thwith
Code, you
Code, you must forthwith comply with such provtsloru or thb permit shall be
co Workers' such povigi.. orthh, permit s Laborbe
seemed revokes.
CONSTRUCTION LENDING AGENCY
I hembyaffirenthar there is a construction lending agency forthe perform
arm ofthe work for which this permit (a law3Bei(Sec,Cw.C.)
Lenders Name
1.endere Address
I certify(hall have readthb application and state thattheaboveleformatlon
i+conca. Iagrcetocomplywlthalldtyendcounty°rdlnancasandrtatelaws
relating to building construction, and hereby authorize representatives of this
city to erste upon the abovnmentiomad property for inspection purposes.
(We eto save, Inde nd krep In n'mrhe Cityo(C=pertlno
.gal la ties,judgments, and expenses which may In anyway accrue
ail. t dCit ro ca the granting ofthls permit.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
GREASETRAP
SEWER -SANITARY -STORM EA. 2WFT.
WATER 14FATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Recel t#
WATER SYSFEM/.TREATING
NEW RESIDENTIAL PLMB. :+oFf.
-
TOTAL:
]WILDING FE
SEISMIC FEE
TOTAL:
ELECTRIC FEE
^DD
QTY. MECHANICAL PERMIT FEE'
PLUMBING FEE
pQ
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD 7O MFGH.
Date RCce1Pt#
AIR HANDLING UNIT (TO 10,ODOCFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CIM)
CONSTRUCTION TAX
Signature plica t Contrattor pare
HAZARDOUS MATERIALS DISCLOSURE
Will eappllam or future building occupant store or handle hazardous
materW as defined by the Cupertino Municipal Code, Chapter 9.17, and the
I R alth and Safety Code Section 25532(.)7
YesNo
Wllltheapplicant or tum building occupant use equipment ordevices
which eodt hazardous air mnlaMru cats as defined by the Bay Area Air
Quality Management District?
4YC9 gN° q p
have ealtha out mune, Sections an 2 er6.95 of
the endo mia Heiith A Safety Code, of c one 25505, 25533 and 25534. I
that itbmy
understand that lithebuildingthe occopoes of t emel immve at which
prior respoto isemym nal(ytheoccup et (Occupancy, lremenis which must be met
prior to Issuance of Certificate of Occupancy,
IXHALE;THOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Date RCCeI f#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
^ -�
va--�
VENTILATION FAN (SINGLE RFSID)
ISDATE
SEP 111990
City ot Cusandano
•7 P�sw
�n 1'
ISSUED BY: a vlgz
BOILER-COMP(3HP OR 100,0(3 BTU)
BOILER -COMP 100,000 BTU )
NEW RISIDFNTIAI. MECH. SQ.FI'. '
_
Owner or aurhorlmd agent - Data -
TOTAL:
OFFICE COPY