21653APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USEBALL POINT PEN ONLY
Building Project Identification -
Bu ding Address:
tae Ke
PEIRMITNO,
21653
weer. a one.
-
CITY OF CUPERTINO-BUILDING DIVISION
'APPLICATION / PERMIT
BUILDING ELECTRICAtePLUMBINC MSCI IAMCAL
,
r !
l ^_ —1
Cyrat�e°r'a Name: uo N.
ra t
CATEGORY CONTROL # ,
'-' hBUICDING PERMIT INFO -
�t'
Architect/ ginear. Llc. No:
�
PERMIT
QTY"PEE'
.,•
Addresc
,ELECTRIG
PERMITISSUANCE
❑ ❑
. LICF.NSEOCONTRACTOR'SDECLARATION
Ihereby affinerhat l am licensed under provblons°f Chapter9(rommenc-
limosshla5iedf1on7000)aon(dDlvifect' oflhe Bumnessand Pro(eseVone Code, and my
Y-2Lk.9 "q
Date' Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following means.(Sectlon 701.5, Business and Professions Code: Any city or
c ntywhichrequlreaaper tWcomu c"ter,impmve,demollah,ormpalr
anystructum pectin its bsuance,alsorequlresthe appliceniforsuch permit to
file a signed statement that he b licensed pursuant to the provistom of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
slon3 ofthe Business and I'm fessloru Code) orthat he is exempt theref meand
the basis for the alleged exemption. Any, violation of Section 70315 by any
jects the applicant to a dvil penalty of not mom than
applicant fora pemdt mbD
five hundred dollars (SSW).
�I, as owner of the property, or my employees with wages as their sole
compensation, wBldo the work, and theslructure is not Intended or offered for
sale (Sec. 7044, Business and Prolessiom Code: The Contractors L1ceve Law
does not apply to an owner of property who builds or Improves thereon,and
who does such work himselfor through hisown employers, provided thatsuch
improvenents are not Intended oroffered!°reale. If, however thebuilding or
ImprovementbsoldwlthinoneyearofcompleioNtheowner-bullderwillhave
t r�rdenof proving that M did not bund or Improve for purpose of .).
U I, as owner of the property, am exclusively contracting with 11
contractors to construct the project (Sec. 7044, Business and Professions e:
The Contetchoes License Law does nal apply to an owner of property o
Wilds or Improves thereon, and who contracts for such'pjoleca with
.cgR(lador(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. B k P C for this o.
-
APPLIANCRSRF.SIDENTIAL,
•�„JOB DESCRIPTION
swiJ��
-2License
PANES
701-1000 AMT'S
. OVER 10)0 AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
-
SIGNS ELECTRICAL
5PECIALCRCLIIT/MESE
TEMP. METER OR POLE INSf.�
POWER DEVICES
SWIMMING POOL ELILERIC
OUTLETSSWITC EXFURES
VALUATION
NEW RESID• LECTR SQ.FI,
STORIES
TYPECONS'IRUCTION
'
TOTAL:
�_
QT7, ' L' BING'PERMIT„', , t� iFEE';�'
TTI CE E
IN A, AIER EBA)
OCC.GROUP
RES. UNITS
FLOOD ZONE
APN
AIX FLO PRO CE
DRAINS A COND.
_
',jr',.' FEE SUMMARY”
UPSIDE H71-9
SANITARY Y . N
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a cenNote of consent to mlfdnsureFIX
,
cenificateofW.Awns Cemperuationlruurance ora mnifled copythereof(Sec.
3800, lab C.)
fairy#
SCI70OLTA% Y_ N
RECEIPT X
GAS S N -I II C.40U1LEI5
PARK ITE Y N
RECEIPT#
CAS EA AVFR4(EA)
Com any.
BUILDING DIVISION FEES
� e ed
. Cenified copy b herebyfurnished.thcity
erdfled copy is filed withthe .Irupectlon division:
CERTIRCATEOP 101MPTION FROM WORKERS'
COMPENSATION ION INSURANCE
(71,19section need nseaW compldM tithe permit b fororie hundred dollars
($1I coo ssJ
booed,
I llnet that o anyhe person In aof ny
I shall not employ any person In any runner n ss to become subject to the
coney sorwtobeco become
pplic i Compematlon laws of Cailtomla. Date
Applicant
NOTICE
NOTICE 7o APPLICANT: If,a after rruking(his cation provisions
ro is Exemption, you
shouldou at
the Workers' Compensation p orthiomofthe Lab be
Code, you must (onhwlth comply with such provlsloiu or this permit shall be
deemed revoked.
' CONSTRUCTION LENDING AGENCY
I hereby afflrmthat them Is a construction lendingagency forthe perform-
arm of the work for which this permit is named (Sec. 3097, Civ. C.)
Lordoare Add as
I me By that l have mad this application and mate that the above information
bcorrect. Iagreetocomplywhhallcityand county ordinanmend mate laws
thio
relatingtobut upont rorutmdlon,endhereby property or In reprexn purposes.
cityW)ato reetosave Inde -mentioned kehrfor inspection purposes.
(We) agree t° save, indemnity an d ices harmiess the City of Cupertino
against lbblllties,' lgnen ,costsand ex rase which may in any way amus
agalr Cityr cansc( c fthc gr o(,his pertnll�L11
Slgnatu of — DatagT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicants funim building occupant atorc or hand In haurdoua
material a, defined by the Cu pereno Municipal Code, Chapter 9.1 7, and the
Health and Safety CWP Section 35537(a)7
❑ Yes ' u No - -
Willtheapplicantorfuture building occupantuse equipment ordevices
which emit hamrdous air contaminants as defined by the Bay Area Air
Quality Management Distrid7 -
4 Yes Na
have read thehazarcuss rruterbls requirements underChapter 6.95 of
the GEfrnla Health ASafdy Ccde,SectIom7550S, 25533 and 35534. 1
understand that if the building dons not currently have a meant, that it is my
responsibility to of thekate.ntofthercqulrementawhich must he met
priortobilityceofdy the occupantmhe req '_
GREASE/INDSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
DatC RCCCI t#
GRFASETRAP
SEWER -SANITARY -STORM EA. 700FI.
WATER HEATERW/VENT/ELECTR
ENERGYPEE Y N
. —
PAID
Date ROCei t#'
WATERSYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQ.Fr.'
TOTAL:
BUILDING
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY.. 'MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
'Date Receipt#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
AIR HA LADLING EMT (OVER 10,000 CFM)
CONSTRUCTION TAX
ExtuUST 110013(W/D=)
CONSTRUCTION TAX PAID:
HEATING UNIT OO I BLOW BTU)
_
Date Reeel t#
HEATING UNIT (OVER I00,000 BTU)
TOTAL:
_
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Pi 9 1991
e��
C
ISSUEDBY:
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVIR 100,000 BTU) _
NEWRESIDENTIALMECH. SQ.FT.
Owneror'authorlud agent Data
TOTAL:
OFFICE COPY