19948,
APPLICANT TO FILL IN INFO.teaRMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
-
Building Project Identification -•
Building Addma:
22440 Walnut Circle
PERMIT NO. 9 9 4 8
nersName: Phone
Loewy 257-7133
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MECHANICAL
Contractors Nave: Lic. No:
_ .. A. A. Furnace Co. 08050 3 6
CATEGORY
CONTROL 0
Architect/Englemr. Lie. No;
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
POWTISSUANCE
❑ ❑ 1:1LICENSED
CONTRACTOR'S DECLARATION
I herebyaffirm that lam licensed under provisions of Chapter 9(cemmene
I Sfos(tXD).f Division3o(the BualnefsandPro(esslonsCode,and my
It
Ilcenee le n fuB fo �a�97,ad �Rf!(ed
Lkenar,Dha} 4_`.�Ill3.'- #L3-4-6.3.6.1
Date ``11 J UU conmdorA—F u r n a c e
- t ARCHITECTS DECLARATION _
I understand my plam shall be used As public remora
Licensed Professl.nsl -
OWNER -BUILDER DECLARATION
I herebyaffirenthat I am exempt fromthe Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
counlywhlch roqubeaa perMttomrmm
truct, alter, improve, deollsh,arrepalr
anystmmmpr rtoitsW ance,.l m-quimtheappBantfmsuchper tto
file a signed statement that he Is hesmed pursuant to the Provisions of the
Contractor's License Law (Chapter 9(mmomming with Section 7000).( Divi-
slo t3of thellusinessand Prafe®bm Code) arthal he V exempt therefromand
the basis for the alleged exemption. Any violation of Section 701.5 by any
applicant fora permll subjects the applicant to a civil penalty of not morethan
five hundred dollars eSM.
F1 1,....r of the properly, or my employees with wages as their sok
compensation, will do the work, andthe structure V net Intended or offered for
sale (Sec. 7044, Business and Professions, Code: The Contractor. License I..
does not apply to an ownerof pmpertywho bu0dsorlmprovesthereon,and
who does such work himself orthrough his own employees, provided that such
Improvements are not Intended oroffered (.rule. If, however lhebuilding ar
improvement issold within au yearof completion, the ownerbudderwill have
dt-widen of proving that he did not Wild or improve for purpose of sale.).
Lf 1, as owner of the property, am exclusively contracting with licensed
mntractwa to consimct the project (Sec 7044, Business and Professiaru Cade:
The Contractor's License Law dm not apply to an owner of Property, who
builds or Improves thereon, And who contracts for such pap" with a
cglltjador(s)Bmnsd pursuant tothe Contractor'sLkxnAe Law.
I—J I arm exempt under Sec B Is P C for this recon
APPLIANCESRFSIDENTIAL
JOB DESCRIPTION
I
PANELS
211-1010AMPS
OVER 1000 AMPS
SQ. FF. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRC /MSC
TEMP.METIROR LE T.
)OWER DTVI
NG POOL
O .� JRESW� (I
VALUATION
NEW DPMI L TR SQ
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY, BING PERMIT FEENLODUZDNE
OCC. GROUP
RGS UNITS
PERMIT ISSUANCE
ALTER -DRAIN k VENT -WATER (EA)
ALN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FDCTURES. PER TRAP
SANITARY Y N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
Ell hereby affirm that I have a certificate of consent to self-imum, or a
cenifients, & Workern Comperuatl.n Insuranceor a certified copy thereof (Sec.
3800, Lab C.'•
Polley« Wei 60-6781023
SCHOOL TAX Y N
RECEBT «
GAS. FA. gYBTEM-1 INC.4 OUTLETS
PARKFEE Y_ N_
RECET«
GAS -EA. SYSTEM -OVER 4(EA)
Com any
[�CcmflAd py he th the cd
city
J1 CcrtlBed ropy b (I4d with the city Inspection division.
7i CERTIFICATE OF EXI:MITION FROM WORKERS'
COMPENSATION SATION INSURANCE
(This section need not becomplMed B the permit Is for orae hundred dollen
($l OD)or leas.) candy
rtify that In the performance of thework forwhlch this permit is issued,
I
I shall not employ Any person In any manner so As to become subject to the
Workers' Compensation Laws of California. Date
Applicant
NOTICETO APPLICANT: If after making this Certificate of Exemptlon, you
should become subject to the WorkesComperuati.n provisions of the Labor
Code, you most forthwith comply with such provisions, or this permit shall be
deemed revoked.BUILDING
CONSTRUCTION LENDING AGENCY
I hereby offirm that there Is a cooatruction lendingagency fortheper(orm
ance of the work for which this permit Is Issued (Sec. 3097, Clv. C.)
tender'. Name
lenders Address
I mr(Ifythatl have readthisappllcationand 9aty mellm.an. Information
is 00rteM. I agree to comply with all city and rounty ominancea and state laws
relzting m bulldleg construction, and hereby authortu represntatives.tthts
city to enter upon the abovo-mentioned property fm inspection purposes.
. (WA) agree to save, Indemnify and keep harmless the City of Cupertino
against pdgments, cost d expenses which may in anywayacxxue
a tuld City naneequc he granting of this permit.
signs ppll est .est—
NAZA SMATERIALS DISCLOSURE
Will the applicant or tumbullding occupant store or handle hazardous],
material as defined by the Cupertino Municipal Code, Chapter 9.IZ and the
Hrallh and Safety Cade Secilon 25532(.)?
r-1Yes3n No
Will the applicant or future building occupant use equipment or devices
which eMt hazardous air ac ntzminsels as defined by the Bay Arca Air
Quality Management District?
Yea a0No
Wave read the Norequirements under Chapter 6.95 of
the California Health&Safety Code, Sections 25505, 25533 and 15534. 1
unde that i( the building does not currently have a tenant, that it is my
ponslblllt o noddy the onvpant of the requirements which must be met
prior to lnua ce Certlfi Occupanin
dC'�-9-3r
BUILDING DI VISION FIi ES
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recef t#
GREASE TRAP
SEWER -SANITARY -STORM FA 200Ft'
WATER HEATER W/VENT/ELGCTR
ENERGYFEE Y N—
— —
PAID
Date RCcel t#
WATER gY��/71iEATIMC
NEW RESIDENTIAL PLMB. SQ.Ff.
TOTAL:
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
l PERMIT ISSUANCE 12.00
FEES PAID:
ALMORADDIOMECH.
Date Receipt#
1 AIR HANDLING UNIT (TO 10,000 CFM) 9.00
SUBTOTAL:
AIR I II NG UNIT (OVER I O,ODO CFM)
CONSTRUCTIONTAX
EXHAUST HOOD (W/01X:7)
CONSTRUCTION TAX PAID:
HEATING UMT(TO100,000BTU) 9.00
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
1—,210000
VENIILATION FAN (SINGLE RESID)
ISSUANCE DATE
g R�
AI
T
SGP 1 1990,
'
(st{sa�as?f jr�p�.�}4�-a,I�p�lsg, �.
ISSUEDBY: y "•l/Wi Ra �"`�S'••^"C1.
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ1T.
Uvn .gen —lal�—
TOTAL: 30.00
OFFICE COPY