21104APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY j— q"%G/
building Project Identification
Be ild ing Address:
o�Is— v �-oT�P�C �J
PERMT NO,
21104
W11er9 arae: ens:
{–tPR--kFtl.,JI
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
10-4—?0
7
ctor'�e1N me: I
35
G — 67
BUILDINGELECMICAL-PLLTMBING.MFCI IAMCAL
CATF-GORY
CONTROL#
Archµ�l/EVjee Lic. Na
K . IV \�) C - 5366
QIy ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add...
19 9
I`
PERMIT ISSUANCEI G7
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provlalonso(Chapter9(corrmene
ingwlth Eemon7000)ofDWielon3ofthe Businemand PSP�o fesslomCode,andmy
license is In (u���(((ope and affect.
Licen =ass cont
Date F -y, C er�
APPLIANCES -RESIDENTIAL
JOB DESCRPTION
PANES
HITS
ARCHITECTS TIONmemo
ARC hall be used as public
(understand my plans shag be used sspublicremrde.
AMPS
OVER
OVER 1000 AMIs5
SQ. FT. FLOOR AREA
5/SQ. Fr.
I SIGNS ELECTRICAL
Licensed Pro(mhmal
OWNER -BUILDER DECLARATION
I herebyafRrrothat l am exempt from the Contractor'. License Law forthe
SPECIALCBTCNT/M15C
` •}�`_Y
TEMP.ME7Q2ORI'OLE (NST.
following mum. (Section 70115, Business and Professions Code: Any city or
countywhlchrequire.apem ttommtmct,altep Impmve,demolish,orrepair
e
anystructure priorto its issuance, also requlrestheappBcent for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
slon3 of the Busineuand Prof.slonsCode) orthat heb exempt therefromand
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the basis far the alleged exemption. Any violation of Section 70315 by any
appllmnt (ora permit oubjeds theappllcant to a dvil penaltyof not merethan
OUTLETSSWITCHESHXTURPS
I B� 1 q I• r
NEW RESIDENTIAL ELECTRSQFr
five hundred dolhrs(ripQ.
ownertheproperty, or my employees their sole
ne
STORIES
TYPECONSTRUCTION
Inwithwage. r
s
compensation, ll do the d for
dile(Sec. Business and
Busies...andf property Code:The
Professions Code: The ntractIntenr License law
Law
does h.d.not apply ,khian vnerofth.g property who builds i ,p.1lhdth.t and
apply orimpom,csI hersoe
who doe. suchwork himself hisownemployee, provided that such
OCC.GROLW
RFS UNI75
ed orwgh
Improvementsam sold intendneyear fcomered orule. the ow er-Wilderwfli have
' Improvement bmld within oneycara(compldlon, the owner-bu0derw0l have
t"mienofproving that he did notWildorimprovefurpurposeo(ule.).
L as owner of the pmpery, am exclusively contracting with licensed
metractos to com uct the project(See 7064, Business and Professions Code:
\ TOTAL: 0s 156
QTy, PLUMBINGPERMIT FEE
PERMIT ISSUANCE
2[(xf
FLOOD ZONE
AIN
The Contradoe. License Law don not apply to an owner of property, who
Wild. or Improves thereon, and who contracts for such p(vpeb with a
cgRt(odor(a) Ranmd pursuant to the Comrade. License Law.
LI I am exempt under Sec. B & P C for this reasonOUTSIDE
-
ALTER -DRAIN & VCNT •WATER (EA)
-
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FIAN
DRAINS FLOOR ROOF, AREA, CONE.
SANITARY Y N
0
Owner Dec.
WORKMAN COMPENRATIDN DECLARATION
❑I hereby affirm that I have o certificate of consent to DulfAnsum,pythe=f ora
3ST0,�niLatewfWerkera Compensatlonlnsurance ora certl(kd mpythemof t5m.
Lab C.)
FIXTURES PER TRAP
-- - -RECEBrf
SCHOOLTAX Y— N_
RECEIPT M
GAS -EA. SYSTEM -1 INCA OUTLETS
PARK PER Y N
Polis
Coman y
GAS P.A. SYSTEM-OVER4(EA)
DINC I
BUILDING DIVISIONFEES
Certified copy b hereby furnished.
Certl(Ied copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE
(rhisseclion need nes becompleted lfthe permit Lsforone hundred dollars
CREASE/INDUSIRI: WASTE INTERCEPTOR
P 'ECIC PEE
PAID —
Date Recei t
GREASE TRAP
SEWER -SANITARY -STORM EA. 200FT.
(5101)orless3
I centrtify that In any personhe in any
I shall not employ any person I" any manner m u to become subject to the
m neerwork so as to b cornhis crank b issued,the
WmkeraCmnpruati.. Uwe o(Call(ornb. Date
WATER HEATER W/VENT/ELECTR -
ENERGYFEE Y N —
PAID
WATER SYSTEM/TREATING
Applicant
NOTICETO APPLICANT: If, after making this CertRlrate of Faemplion, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
Date Remi t#
NEW RESDENIIAL.LMB. SOFT,
d
AL:
D NG, Q
FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hembyaffirmthat there baconstruciion leadingagencyforthe perform
ance of the work forwhich this permit S issued (Sec. 3097, Clv. C.)
Lender's Name
Lendees Address
I mrtifythat I have readthb appliw/ionand rt.Mthatthe above infomntion
h purred. I agree to comply withaB cityand countymcilranm and slate laws
TOTAL:
r70,00ELECTRIC
FEE Q
PLUMBING FEE O
QTY. MECHANICAL PERMIT FEE
MECHANICAL �[
PERMIT ISSUANCE,, -----\
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter a Pon the AWmentioned property for inspection pu rposes.
(We) agree to save, IndemNty an d keep harmless the City of Cupertino
a �L�
Date ReeCi f#
P
ALTER OR MECH,
against llabllltles,jud s, mstsa zpensesw mu nanywayac .
against uidC tyl sequences egrenti this IL
NDLINGUNIT(r010,000 )
SUBTOTAL•
AIR HANDLING UNIT (OVER 10,000�kx
CONSTRUCTION TAX
EXHAUSTHOOD (W (sen
—
CONSTRUCTION TAX PAID:
Sig o Applies re or to
DOUS MATERIALS DISCLOSU
HEATING UM BTIn
—
Wllithcappll for (oto building occupant Gore or handle hazardous
mulerbludefined by the Cupertino Municipal Code, Chapter 9.17, and the
Date RCCCI t# a
_
HEATING UM 100, N
TOTAL.
Helth and Safety Code Section 25537(a)?
oYes ,Q No
Wi)lthe applicant..fum.bullding occvp.m.seequlpmentordrO
which emit havardcu3 air comaminard. a. defined by the Bay Arca Air
Quality Management District?
No
VWfI •A N �RFSIU,
IS ATE( s�ry
—Y
/1�R 1 1991
A
BOILFR- OR 00,0(10 BTU)
BOILCR-COMP V 100,000gTU)
Oyes 4
have read the hazer uses materials requirements under Chapter 6.950
the Ca11(omla Health & Safety Code, Sections 75505, 25533 and 25534. I
NEW RISE DENTIAL MECH, SQ.FT.
understand that if the building does nes currently have aone et, that it b my
rap-mibilityt..&ifytheoccvpa"tofthercquim"nnl.whlchmustbemct
Pi MS
C .
prior to bsuanmof a Certificate of Occupancy.
;�` ^ �
ISSUEDBY: ".`� P(%—W uzr—t
Owner or authorised agent Date
TOTAL: 9 a
OFFICE COPY