20421APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building project Identification
Rullding Addrcas:
PENUTNO.
0 4 21
10100 Torre Ave. Unit 221 F1.7
G 4 G
2
wners ame.�Y� v e one:
bier ro erties
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A .
5/10/90
Contractors Nam: Lic.No:
738-4444
BUILDING ELECTRICALPLUMBING-MECHAM
CATEGORY
CONTROL
aCAL
Architect/Engineer. Llc. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
a a a
PERMITISSUANCE 12a
LICENSED CONTRACTOR'S DECLARATION
therebyaffirm that lam licensed under provisions of Chapter9 (comment-
Ingwlth5ection70DD)o(Dlvldon3ofrise Buslnessand ProlessloneCode,and my
11... Is in full force and effect
AIsIPLIANCESRESIDENMl
JOB DESCRIPTION
RCB
PANELS
License Class Lica
Date Contactor
e F
..l �Ar
201-1000 AMPS
ARCHITECPS DECLARATION
I understand my plats shall be used as public records.
OVER1000AMPS
SQ. FT, FLOOR AREA
S/SQ.FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I herebyaffirmthat l amexereptfrom the Contractor's License Law forthe
following reason. (Section 70015, Business and Profemions Code: Any city or
crony which requim a permit to construct, ilteq Improve, demo W h, or mpalr
985
74.92
TEMP. METER OR POLE INST.
anystsuctum prlorto its issuance, also requlrestheappllcant forsuch permit to
file a signed statemntethat he h licensed pursuant to the pnevulors of the
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divl-
slon 3 of the Business and Professiaa Code) mthe he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not morethan
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLRTSS'WITCHE&FIXTURES
VALUATION
$73,796.00
NEW RESIDENTIAL ELECTR -
�'�'
five hundred asrcddolhrshepr).
❑ I, as owner of the property, or employees with wages thele sole
STORIES
TYPE CONSTRUCTION
compensation, will do the Businesaworkandims, Code: hnot Intended orofferedfor
he r
.in (Esc. Pro(essbns Code: The Contactors thereon Law
V_N
apply to an owner
s.ch loan owner of property who nem or improves y.,prvided thereon, and
who ddoes oess.ch
wprove ent am nothimself dedorughed owns. If,ho evert ebuildtsuch
Improvementsarenot Intended earofco (pewit.If, however, deer ill have
Improvement bwldwlthlnoneyearefcompldbrythcowner-bu0derw111 have
TOTAL:
OCC.GROUP
R-3
RIS. UNITS
f
tikakurdan of proving that he did not bund or Improve for purpose ofsale.).
U L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
QTY, PLUMBINGPERMIT FEE
FLOOD ZONE
MIN
PERMIT ISSUANCE 1'Z
The Contrector's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who rontacts for such p(ujects with a
ogntf+ctor(Olicensed pursuant to the C.mrsdor's License Law.
U I am exempt under Sec B & P C for this reason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FIN
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N_
RECEIPT p
Owner Date
_Date
WORKMAN COMPENSATION DECLARATION
[31 hereby affirm that I have a ceslfiate of consent to self -insure, or a
rertlncab o(Worken'Camperwtlonlnsuranaara certified copythereof 6ec.
38 W, his CJ
p
pp(TUgEq PER TRAP
SCHOOL TAX Y_ N_
RECEIPT X
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N —
M
RECEDINC
Collry
Company
GAS EA. SYSTEM-0VER d (EA)
DT
9UILDINC DIVISION FEES
Ified copy h hereby te
ry
ertdled copy h filed withh the cityInspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFE•E
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WOR KERS'
PAID
COMPENSATION INSURANCESLIVp-R-SANn.ARY-B.IbRM
(Thlsseed.. need nae becompleled lithe permit hfor one hundred dollars
FA.2WFf.
Date Remi tM
WATER IiFATER W/VENT/ELCCTR
ENERGY FEE Y_ N_
PAID
(SIOD)orless.)
I certifythat N the performance of thework forwhlch this pemdt h issued,
I shall not employ any person In any manner w as to become subject to the
Workers Compensation LewsotCallfomia. Dare
WATER SYSTPM/TItEAT[NG
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date RCCpI Ii!
NEW RESIDENTIAL PLMB. SQbT.
TOTAL:
BUILDING FEE
5212.5
Code, you rust forthwith comply with such provisions or this permit shall be
deemd revoked.
SEISMIC FEE
5.18
CONSTRUCTION LENDING AGENCY
Thereby affirm that there is a construction lendingagency for the perform
ance of the work for which this permit b Issued (Sec. 3097, Civ. CJ
Lender's Name
tenders Address
I certifythat I haveread this appllationaM statethat theabovelnfamentlon
Is corned.I agree to comply with all city and county ordinances and nate laws
TOTAL:
ELECTRICFEE
3—
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE 12
PLUMBING FEE
36,
MECHANICAL FEE
FEES PAID:
36.63
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentloned property for Inspection purposes,
(We) agree to ave, Indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may M any way amus
ALTER OR ADDTO MECH.
Date Rmei t#
P
AIR HANDLING UNIT ITO 10,ODD CFM)
SUBTOTAL:
V17 -
againsteald o neo a an Rg of this permit.
r O
AIR HANDLING UNIT(OVER 10,000CI•lt)
CONSTRUCTION TAX
Signature of Appliart/Contractor tate
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATRRWSDISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
Will the applicant or future building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
HFATING UMT (OVFR 100,000 BTU)
TOTAL:
I Ie❑xlt Yaesnd Safety Codn SSleNioon 2S532(a)?
VENTILATION FAN (SINGLE RESID)
ISSUANCEDATE
Will the applicant or fu him building occupant use equipment or devices
which emit hazardous air cuntamitunts as defined by the Bay Area Air
Quality Management District?
Yes No
haveread the haze ous materials regWrements under Chapter 6.95 of
the California Health &Sahty Code, Sections 25505, 25533 and 25534.1
understand that if the building does not currently have a tenant, that It is my
r I�
BOILER -COMP OHPOR 100,000 BTU
BOILER-COMP(OVER 10LD00 BTU)
NEW RESIDENTIAL MECH. SQ.ET.
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certiflate ofOcropa my.
�I Of �II!1?li�flll
SGL
ISSUED BY: IA
Owner or authorised agent Date
TOTAL:
OFFICE COPY