29865APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
I;'CITY OF CUPERTINO , BUILDING-ELELTRICAL
BUILDING DIVISION APPLICATION/PERMIT • PLUMBING. MECHANICAL.
BUILDING PROJEC7f IURNTIFICATION
PERMIT NO. ^ �+
29865_ 9 8 6
J N V
BUILDING ADDRESS:
20730 S1-eve,nS Cr-tc.k - w
SANITARY NO:
APPLICATION SUBMITTAL DAI'H
OW EIl'SNAME: j PH(INE:
\ Y 5
C)NTRACfOR'SN MG a LIC NO'.
C I T
N/C
❑
CONI'Il
ARCHI'FF,CT/E o1NEER: LIC NO:
ADDRESS:
1 l 4SgS
CONTACT: PHONE:
Cb,IY6 sio
-
El Consultant Fees Paid by Applicant (Initial) -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ;K ❑ ❑ ,
LICENSED CONTRACT' OR'S DECLARA'I']ON
I hereby affirm mot I ant licensed under provisions of Chapter 9 (commencing
:with Section 700(1) of Division 3 ofthe Business and Professions Cade, and my license is
in full force and effect
License la Lica ����� t`?
Dam �'�fJ Contmc
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDnEON ❑PLUMBING RE -PIPE
❑MULTIUNIT ❑STRUCTURAL '
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
11 BAT] RE A01 N
r'
[:101 H -
�a {
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I understand) my plans shall be used m,.bhe recods
PANELS
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Committers License law far the
following reason. (Section 7031.5, Business and Pr fessions Cole: Any city or county
which reyuires o permit ut corarma..ince improve, demolish, or repair any yhortme'
prior o its issuance, also Implies the applicant for such Permian file a signed statement
that he is licensed pursuant to the provisions of the Coutmemr's License Law (Chapter 9
(commencing with Section700hof Di,m...13 of the Rusinessund Professions Code) or'TEMP.
that he is exempt therefrom and 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
t mmathan five hundred dilet,($500).
I, as owner of the Imperils, or my employees with wages as their sole compensation,
will do thework, and the structure is not imended... flered for vele (Sec. 7044, Business
cast Professions Code: The Contractor's License Law does not apply m an owner of
property who builds., improves thereon, and who does such work himself or through
his awn employees, provided that such improvements are not intended or offered for
sale. If. howevu, thebuild'mgor improvement is sold within oncycerofe,mplethar, then
menervhuilderwill have meburelenofproving that hm edidnNeild nr impmvc lie par-
u
poofmla).
1, as owner of the property, am exclusively contracting with licensed contractors to
convect the project (Sea. 9044,11usiness and Professions Ca,.... The Gmtmt9.. -.i.
cease law does not apply man owner of property who builds or improves theater, and
who contracts for such projects with a contmetons) licensed pursuant a the Coatmemrs
License Law.
❑ l an exempt under See. ,B&P C for this Basan
201-1000AMPS
OVER IgOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
M In ER OR POLE INST.
0
COMMERCIAL
0 NEW BLDG/AUDITION ❑ DEMOLITION
❑TENANT ❑FOODSI:RVICG
IMPROVEMENT
[I OTHER
POWER DEVICES
SWIMMI NO POOLE LECTRIC
OUTLETS - SWITCHES - FDCPURHS
NEW RESIDENTIAL ELECfR SQ Fn
SQ. FE FLOOR AREA
//��
10 �
pq
JUN 3 1996
iI% Ur (cl s ,.
SJSQ, FT.
s '
QTY PLUMBING PERMIT FEF.
PERMIT ISSUANCE +
ALTER- DRAIN & VENT- WATER BEA)
O wner Elute
' VAIS ATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I Lose ad wt. 11 model. a Cenificme of Crustal to eel f -insure for Worker's Contpen-
smem, as provided for by Section 3700 of the Labs Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compcnsmian Insurance, as required by Section
3700.1' the LaMn Code, for me perl'o..aneeof be work for which this perm is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: -
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section neeJ not be cnmpluul ifthe permit is fnrnne hundred dollars Ib 100)
or less.)
I certify that in the performance of the work for which this .is is issuaL l shall
not employ any person in any manner to Wcryryn blecuo the Workers C.,a,n-
cation Laws of Cal' .rota. Dere s8 +3/ "'� (n
Applicant �'TiQe kL>T
BACK FLOW PRO 'I=..DEVICE
DRAINS- FLOOR, ROOP, AREA, COND.
'STORIES
TYPE CONS'TRUC'TION
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS'
OCC. GROUP
APN
GAS - EA, SYSTEM -OVER 4(EA)
GREASMNDUSTRI. WASTE INTERCEPTOR
HULLOING DIVISION FEES
GREASETRAP
PLANCIIECK Plili
SEWER -SANITARY -STORM EA. 200 Fr.
-
ENERGY FEE
WATER HEATER W/VENT'/ELECI'R
GRADING FEE
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, youshould
NOTICE
beutme subject ns the Worker's Compensation provisions of he Labor Codemin
, you t
forthwith comply with such provisions or this permit shall be deemed resume.
CONSTRUC'DOW LENDING AGENCY
Iberebyuffirmdatutere onsu
isocurom lendingagency for the Performance.
he work foe which his permit is issued (Sec. 309], Civ. C.)
Lenders Nmnc
WATER SYSTEmn BEATING
SOILS FETE
WATER SERVICE:
PAID
Dam Receipt#
NEW RESIDENTIAL PLMR. SQ. FT.
TOTAL:
Lenders Address
TOTAL.
QTY, MECHANICAL PERMIT FEE
BUILDING LEAD
1 certify that I have read this application and state that the above information is
toren, I agree a comply van nil city and narnry eminences trod state laws mluting to
building commuction, and hereby nuthoriu representatives of this city to enter upon the
above-mentioned property for inspection proposes.
(We)agree to save, indemnify and keep harmless the City of Cupertino against
Imjdhtin,judgmenu,cmtsand expenses which may in any wtryaccmeu,most said City
in consequence of the grunting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON2'OINT
REGULATIONS.Eoe,p�^�iq(
- -
SEISMIC FE
PERMIT ISSUANCE
ANTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 10.0(0 CFM)SOURCE
AIR HANDLING UNIT(OVER 10,000 CFM)AXSituationn,
of AppllcanJCummclor�� -Dom
MATERIALS DISCLOSUREWill the applicant or future building occupant store or handle hazardous amesnal
as drained by the Cupertino Municipal Code, Chapter 9.12, and me Health and Safety
Code, Section 25532nd?
[]Yes �Ne
Will he applicant or future building occupant use equipment or devices which
:mit Will
air contaminants as deffted by the Bay Area Air Quality Management
, "i'lP
❑Yea []No
1 have revel the hazardous memdals requ eentnns under Chapter 695 of the Culi-
(aria Health & Safely Code, Sections 25505, 25533 and 25534. 1 undermost that if me
Wilding does not currently have a mount. that it is my responsibility to notify he sccopant
of he resluirernents which most W met prior to issuance of a Certificate of'Ovemeney.
EXHAUST GOOD(W/DUCT)
XHOUSINCMIII
ATIDN FEBHAZARDOUS
HEATING UNIT(TO Raft" BTU)
HEATING ONI'1'(OVER IW,000 BTU)
Rece1pIM
VENTILATION PAN(SINOLE RESID)c
BOILER- COMP UHP OR I BLOW BTU)
TOTAL:
BOILER- COME)(OVER 100,0008'1 ID -
AIR CONDITIONER
ISSUAN ' DATE
ISSUED BY:
NEW RESIDENTIAL MECH.
-.
Owner ur autharieed.sea, Dam
TOTAL11
OFFICE