20351APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification77=—
PERMTNO.
20351
Building Addmss:
'Pnyrpners arm: Aim HIT it, 1 1 tAl
Forte;
AppIJCAnONSUMMrrAr=
ertipcz
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
-
5/10/90
nPnter
Contraar.Name: Lk. No:
�18-4444
BUILDING-ELECnUCAI PLUMBING-MECEIAMCAL
CATEGORY
CONTROL N
Architect/Englexam Lk. No;
QTY ELECTRIC PERMIT FEE ..
BUILDING PERMIT INFO
Address:
EMU RIE
El
PERMITISSUANCE 12
LICENSED CONTRACTOR'S DECLARATION
IhihSyi.(trm0).f Di lk 3.fthe usJroaansof Gapter9di, and
hom.h infuil7000)of Dlviect. the Budnsuand ProfeulonaCode, and my
license Is In (illi force and effect
APPLIANCES -RESIDENTIAL
JOB DESCRIPI70N�
D ,�v..iff
PANELS
License Class Lk.a
Date Contractor
RCB
3014000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used upublic moods.
OVER IOW AMPS
SQ. FT. FLOOR AREA
S/SQ. FI.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BOLDER DECLARATION
I here's afflrrothat tun exemptfmmthe Contractor's License law for the
y
fallowing reason. (En tlon 7031.5, Budoe.s and Professions Cod.: My dry or
countywh ich requim a pemdt m mnatmct, alter, improve, demo W h, or repair
SPECIALCIRCUIT/M SLC
1,115
74.92
TEMP MEIiR ORPOLE INS['.
anystmmmprlortoibbwame,alwmqul theappUant(w Buchpermltm
file a signed statement that he b licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter9(comenendng with Section 7000) of Divi.
slon3ofthe Buslmu end Profeselom Code)orthat he b exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applkantto a civil penalty of not more than
POWERDEVICES
SWIMMING POOL ELECTRIC
OUTLETS SWITCHFSFE(T'URES
VALUATION
$ 83s 536.00.
live hundred
nerofdollars the pr).
❑I,asownera(the Property, army employees with wageathemsob
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
.1.(Scompea 700 Dust.... work+ndtM1es Code: Tbnot Intended oroffered(dr
sale (Sec, 7064, Business and IarMeuWro Code: The Contnctora License Taw
�1—[s]
does not apply to an owner of property who builds or improves t hereon,and
whodoessuehwarkhbnseUortheough Msownemployees, provided that such
OCC.CROLW
RFS. UNTIE
improvements are not intended orofferedforsale. If, however, thebuilding or
Improvement bsold wlthinaneyearofmmpleioNtheowner-buUderw H have
TOTAL:
R-3
the burden of proving that he did not build or Improve for purpose of sale.).
u I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec. 7061, Business and Professions Code:
Qjry,' -'^: PLUMBING PERMIT :FEE
FLOOD ZONE
APN
PERMIT ISSUANCE 12
The Contractors License Taw does not apply to an owner of property who
builds or Improve thereon, and who contracts ea
for ch PSojecta with a
cgl�IactorW licensed pursuant W the Contractor. License Law.
LJ [ +m exempt under Sec B & P C far this reason
ALTER- DRAIN& VENT- WATER BEA)
FEE SUMMARY
BACKFLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT
Owner - Data
WOR KMAN COMPENSATION DECLARATION
❑I hereby a!(Irm that I hive a certificate of consent to self -Traces, w a
certificate of Workers CompensaHonle urance or. certUbd copythereof(Eec.
3300,Lb C.)
Po11ryN
FI)CEURES. PER TRAP
SCHOOLTAX Y_ N_
RECEIVE 0
CAS EA. SYSTEM -1 INCAOUTLEIB
—
PARK FFR Y N
- RECEIPT
Ca�ny
GAS EA. SYSTEM -OVER 4(EA)
BUILDING DIVISION FEES
LI (fled copy b hercbyttinehed.
ertl(led copy b filed withh ted city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPT OR
PLANCHECKFEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM
(Thlssectlon need no be completed tithe permit b forom hundred dollae
EA 7110F1'
Date Recd t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N—
PAID
($100)orles.)
I certifythat in the performance of the work (orwhich this permit Is issued,
I shall not employ any person In any manner w as to become subject to the
Workers Compensation Lawn of Californh. Date
WATER SYSIE.S/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
NEW RESIDENTIAL PLMB. SQ.FT.
Date Recei t#
TOTAL:
BUILDING FEE
56
Cade, you must forthwith comply with such provisions or this permit shall be
deemed mocked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyatfirm that there Is. construction lendingagenryfor the perform-
ance of the work for which this permit is; Issued Cies 3097, Civ. C.)
lander'sN.me
Lender. Address
I certilythat I havereacithbapplicatlonand nate that theabove Information
Ismrreat l agree to comply with all eltyand county ardlnarom and data laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
39.88
-
QTY_. _ . ;_ MECHANICAL PERMIT'' FEE
MECHANICAL FEE
19, 91q
PERMIT ISSUANCE 12
FEES PAID:
relating to building construction, and hereby authorize representative of thio
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harMess the City of Cu pertNo
against BabWtcro dg --is, m&e and ex erases whlchmaylnanywayaccrue
ALTER OR ADDED MECH.
Dale Recei [#
AIR HANDLING UNIT (TO 10,DDO CFM)
SUBTOTAL:
O
.e.irutuldC may nceo an lig olthis permit.
AIR HANDLING UNIT 10,000 CFM)
CONSTRUCTION TAX
ture of Apphart/Contracr 11 Dae
Signsto
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATE DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recei t#
Will the applicant or future building occupant store or handle havrdous
material as defined by the Cupertino Municipal Code, Chapter 9.13, and the
Health and Safety Code Section 75533(a)?'
❑ Yes M No
Will the applicant orfumrebulldingoccupant use,equlpment ordevims
which emit hauardous air contaminants as defined by the Bay Area Air
Quality Management District?
Yes ❑ No
HEATING UNIT (OVER 100,000 BTI)
TOTAL:
�.
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
ID A �Irf'
�`1 77dd
BOILER -COMP OHPOR 100,000 BTU)
BOILEILCOMP(OVER 100,000BTU)
Ihave read the M1uadous.(criabrequlretrentsunder Chapter 6.95of
the C.lifomb Health & Safety Code, Sections 25505,25S33 and 75534. I
understand that lithe building does not currently have a tenant, that it is my
�1/1� �nfo
J7
NEW RESIDENTIAL MECEL SQ.FT
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of0caupanry.
6t
/s. city Of Cunpt1.y
lflf)
ISSUEDB G
Owner., aulhotlecd agent Date
TOTAL:
OFFICE COPY