21447APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL P INT PEN ONLY
Building Peeled Identification_ �� ejp ��
Building Addreee: •�
o0
0`310 65; lYQJO I
PERMIT NO.
21447
nenName: one;
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
BUILDINC-ELECTRICALPLUMBING-MECEIANICAL
Ali
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C tractor acre�ftz; Lie. Nm
CATEGORY
C
A t / mem LM. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
��YY (nj J Q/j
Addmea NA5L
�dl ItV I
UECI PLUMB M�H
El 1:1❑
PERMITISSUANCE
L
LICENSED CONTRA DR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc
IngwithSm imn7000)of DlvW.3ofthe Buefeessand ProlesslonsCede,and m
license Is In full to. and effna.
License Chea Lk.Y
Date Contractor
ARCHITECTS DECLARATION
I understand my plana shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hercbyatfirm that I am exempt from the Contractor. License Lw for the
following reason(Setl1on 70715, Business and Profembv Code: Any city or
countywhich refutresa permetomrotruct, alter,improve, denollsh,oreepair
anystmRure prlortolts issuance, also requlrestheapplicam for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
Contradoes License Law (Chapter 9 (commencing with Section 7000) of Divi-
slon3 of the Businessand Profealote Code) mthat he be.empt therefromand
the basis for the alleged exemption. Any violation of Section 701L5 by any
applicant fora permit subjectstheapplicant toa clvll penalty of not more than
five hundred dollars t$500).
F-1 1, as owner of the property, or my employees with wages as their sob
compensation, wa(do the work and theetructure isnot Intended or offered for
sale (Sec. 7014 Buslnns and Prefeesloro Code: The Contractor. Lim.. Law
does not apply to an owner of property who builds or improves thermn, and
whodoee wchwork hlmmlf orthrmgh hfsownemploym, provided thatwch
impmv=wrts are not Intended oroffered forme. If, however, thebullding or
improvement bwldwithfnowyearofcompleion,theowner-builderwlll have
t e�yiCTdan of proving that he did not build or improve for purpose of sale.). id
s[y_y,I_• all owner of the property, am excluelvely contracting with licensed
.traders to construct the project (Sec. 7044, Business aPmofexima Code:
Contractors License Lew don not apply to an owner of property who
Wild. or Improves thereon, and who mntmds for such ptoJerts with a
y,NBjjarterial licensed pursuant to the Contractor. License Law.
cul am e.empt under Sec. B & P C for thus mean
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
V/ /
J /L'7
PANELS
201-1000 AMPS
OVER IODO AMPS
SQ. FT. FLOOR AREA
f/SQ. Fr.
SIGNS ELECTRICAL
SPECIALCIRCUT/M15C
TEMP METER OR POLE INST.
POWER DEVICES
SW0r1MINC POOL ELECTRIC
OUTLETSS'WITCHESFIXTURES
VALUATION
Oi/� ?C�
0Vx I
NEW RESIDENTIAL ELECTR SQ r.
STORIES
TYPECONS]RUCT70N
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC. GROUP
RFS. UNITS
pP yT ISSUANCE
ALTER -DRAIN & VFM-WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FI(TURES PER TRAP
SANITARY Y N'
RECEFT M
Owner Date
WORK MAN COMPENSATION DECLARATION
that 1 have o Inatra to of consent to op theme, ora
❑I hereby affiWorkers!
certifiob ofWorkeei Compevatlon]murance ora cenlfled copy themo((Sec.
Poli3800, Lab CJ
SCHOOL TAX Y_ N_
RECmPT M
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
GAS EA. SYSTRM-OVER d (EA)
Cme�an y
BUILDINGDIVISION VISION FEES
Certified copy b hereby famished
❑CemlOed copy b filed withh the the city Impedion division.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(ThIlmec ion need not be completed if the permit b forom hundead dollars
(SI ID)orfen.)
Icenote employ
pesubjecrnint is issued,.the
I shall not employ any perws f any manner w u to become wbMtt to the
erva-onan the work for to become
Workcrv' Compevatlon Iewe of California. Date
Applicant
NOTICEco APPLICANT: If, after oekingfhb Ceetl(late of Exemfhe you
should become subject to the Workers' Compewtlon provisions of tthe Labor
Code,youmustf.nhwithcomplywithsuchprovlalorucurfhb Ne tshallbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyafffrm that there b a mvtmuNon lend Ing agency for the perform-
ce of the work for which thus permit b Issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders address -
] mthlythat l have read this application and.tate that the above fnfornatlon
boomed. I agrnto comply with all city and county ordinances and slate laws
relating to building corawdion, and hereby authortze mpresentativn of this
city to enter upon thea!cave-mentloned property for inspection purposes.
(We) agree to save, Inde d knp h:Vea, the City of Cupertino
agalrut liabilities, judgment s, sa dexpan awhlchmaylnanywayamue
agaimet id Cli 1% onseque of egrant gofihlspermit. p
.ZG
GREASR/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Receipt#�
��
iGREASETRAP
SEWER -SANITARY -STORM EA. 200FT.
WATER HEATERW/VENT/ELFCTR
ENERGYFEE Y N
PAID
Date Recei t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PL.MB. �'FT'
TOTAL:
BUILDING FEE
co
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTERORADDTOMECH.
DRIC RCCeI t#
P
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CrM)
CONSTRUCTION TAX
Ignawm of Applicart/Cont&tur Dater —
HA]AR DOUS MATERIALS DI SCIDS URE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health andSafetyCodeSection 2S532(a)?
❑ Yes M No
Will the applicant or future building occupant we equipment or devices
which emit haeard... air contamnb
buas dellmd by the Bay Area Air
Quality Mawgement District?
4havemadthebazaido.N.0.terfalsrequirereentsunder Chapter 6.95of
the Callfemb Health &Safely Code, Sediora25505,25533 and 25534.1
understand that if the building does not mrmntly have a tenant, that It L my
responsibility to notify the occupant of the requirements which most be met
priortoissuanceofa Certificateof Occupancy.
EXHAUST HOOD M/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
Date RCeeipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)�,,
HeS,S-UANCE DATE
NOV�•Q gQ()j�
v 1990
�4 as� a^4 ^ it
City of re" w.rill,
ISSUED BY:�4' <4 S
BORER -COMP OHP OR 100,000 BTU)
BOE.ER-COMP(OVER 100,000BTU)
NEW RESIDENTIAL MECH. SQ.PT
Owner or authorizedagent Date
TOTAL:
OFFICE COPY