20567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identificationrp/ PEIevUT NO.
Building Addmlssy: d(o 2 0 5 6 7
I0. ) , walFt Q �+ !r-Fina G I
wast, time: IS-�93 8' A A
Ai��iCITY OF CUPERTINO-BUILDING DIVISION /
r. Lic.No: APPLICATION /PERMIT
BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N'��y
Arc it /Englsm. Llc.No: 9 -�—1
5-VL"4 N13-6.79— 0 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:Soo 1`1`10134 CF1 Lc�410
0
I I'FRhtITI55UANCE u ❑ El ElLICENSEDCONTRACTOR'SDECLARATI N
lhmbyaffirmthatlam11cenmdunderpm Womof Chapter9(mm c APPLIANCESRE!7DENTIAL JOB DFSCRp'11ON
Ingwin SeRion 7000)0(Dlvlslon3ofthe Buslnessand PmfessionsCvxJ,and my
house b in full fo and effect. PANELS T
License Cis LIC.N 5-A7 / 70
Date Contractor P&4�rAL **14 4 JQ f vCG
ARCHITECTS DECLARATION 201-1000 AMPS
OmX I understand my plana shall W used as public records. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
(3 Licensed Professional 9GN5 ELECTRICAL
M 60
,< OWNER-BUILDER DECLARATION
�] IherebyafBrm'hat I am exempt fromthe Contnnor'e License law for the SI'ECLkLCEICIIIT/M15C _`JV
Z p '� following reason.(Sedion 7031.5,Business and Professions Code:Any city or
F 2 s, TEMP.MEFER OR POLE INST.
county which requires a permit to construct,alter,improve,demolish,or repair
any structure prior to Its issuance,also requires the applicant for such permit to IIDWFRDEVICES
E a signed statement that he Is licensed Pursuant to the peuvbions of the
3 Contrachn's License Law(Chapter 9(commanding with Section 7000)of Divi- SV✓PLMING POOL ELECTRIC VALUATIO
E,�05 alon3ofthe Ruslneumd ProfessionsCode)orthat helaexempttherefromand f�
�^ the basis for the alleged exemptlon. Any violation of Section 70113 by any OUTLETS-SWITCHESHXTURES
1:1<S applicant for a permit subjects the applicant to a civil penalty of not more than
R live hundred dollars W.,R .�
I,as owner of property, SfOW6 TYPE GDNSIRUCHDN
j.- p perry,or my employees with wages as their sole
7< compensation,willdo the work andthe structure is not Intended or offered for
p sale(Sec.70Ed,Businessand Pro(ewtom Code:The Contradoes License Law
Er 2 does not apply to an owner of property who builds or Imrov
pes thereos,and L (y(� _ OCC.GROUP RES.UNITS
�$^ whodoessuchworkhlmselforthrough hisown employees,provided thalsuch
Improvements are not imended proffered for ole.If,haweveq the W ilding or TO
Improvement hasold within one year ofcomplimon,the owner-budderwill have
tl� rden or proving that he did our Wild or Improve for purpose of sale). QTY. PLUMBING PKRNUT. E
"L as owner of the property,am exclusively contracting with licensedIIMN FLOOD ZONE APN
contractors to occuu ud the project(Son 7006,Business and Professors Code: _ V
The Contractor's License Law does nor apply to an owner of property who ALT1R-DRA
d
Illil
cqN
Wilds or Improves thereon,and who contracts for such p,ojes with a -
(adm(s)licensed pursuant to the ci
Conlraora LlrnBACK FIO
nse Law. OTECT.D FEE SUMMARY
Ij I am exempt under Sec. B k P C for this re
ason SANITARY Y_ N_
Owner Date OUTSIDE FEES
DRAINS RR ',A CO RE-CEPTN
WORKMAN COMPENSATION DECLARATION pDf.1URFS-P SCHOOL TAX Y_ N_
�ry+�J1 hereby affirm that I have a dr igcem or consent to self-insure,ora RECEIPT
AN
ll care ofWorkera Compensation Insurance or a oertlfet copy thereof Ouc. GASF,,A -I INCA O PARKF'EE Y N
3600,lath C.)
Policy N SAD 9/ S 7 l/J
I RECEIPT N
Company .level Ln.s'✓r✓.A�a t.v T: f✓� GAS EA. -OVER BUILDiNGDIVISION FEES
CcrtiBed copyls hereby hmd. d. GREASE/IND L PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EX[MPFION FROM WORKERS' CREASE PAID
COMPENSATION INSURANCE SEWER-SA Y. DOIC RCCCI t# I�7)
(ThlasecHon need eat be cpmplTI lithe Permit hforone hundred dollars '
M00)orleas) W,A.TERHEAW/ / ENERGYFEE Y_ N_
1m ifythat In the performanceorrhewoekforwhichthis permit is blued,
1 shall not employ any person In any manner as as to become subject to the WATER SYSTEM/TREAIING
Workcrd Compensation laws of California.Date
PAID [[1���µµyy��
O Z Applicant NEYVRESIDPNTIALPLMB. Date Recei t# 7�'Lw
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
h' N should become subject the Workeri Compensation provisions of Labor TOTAL:
Code,you=at fort hwith comply with such provisions or this permit shall be BUILDING FEE 6
deemed revokes.
W
— CONSTRUCTION LENDING AGENCY SEISMIC FEB 3
CL e Ihereby affirm that there is a construction lendlngagency,forthe perform- TOTAL: ELECTRIC FEE
7 Z anm of work for which this permit Is uurcif5e.W,Cm.C.) PLUMBING FEE
02 I.rultes Name
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lcenifythatlhavemadthbappBcationaMetatethattheaboveinfoetation
d lscormd.Iagnmtocomplywithallcityand countyardlnances and state lavm PERMIT ISSUANCE FEES PAI D:
relating to building consmacilon,and hereby authorbc representatives of this
(— N city to enter upon the alx, o-mm�tkncd property for Inspection purposes. ALTERORADDTOMECH.
Z
_ Date Receipt# _
V
(We)agreeagree Is,save,Indemnify an d keep harmless the City o(Cupertino
true MR HANDLING UNIT(TO 10,000 CFM)
against liabilities,rydgmenta,cortaand expenses which may In any wayaccme SUBTOTA
against said City in consequence of granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,0)0 CIM)
Slgmtumor Applicam/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant store or handle havrdous HEATING UNIT(TO 100,000 BTT)) Date RCCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
HealthandSafetyCodIon 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL: s
Yes At.
No
Wlllihe handouts torebuilding o=pant use theequipmontBay Area devices VEN"DLATIONFAN(SINGLE RESID) ISSUANCE DATE
which emitnaementaairrdd? vests as dented by the Bay Area Air m
y�
Quality Mamgcrrcnt Dis��srid? BOILER-COMP OtB'OR100,0(IO BTI!)
4Ye, I-M No
have read the hang cam materials requirements under Chapter 6.95 of BOILER-COMP(OVFR 100,000 BTU) 11 '+
the California Health k Safety Code,Sections 25505,25533 and 25530.1 JVI 1 ^� 19SJ
understand that if the building does not currently have a tenant,that it is my NEW REST DENTTAL MECH. SQ.IT
roponsibility to notify the occupant of the mqu lmments which must be fret
Prior to Lssuan eo(a Certillcat otOnvpanry. / City Of Nperinn
Id
Owueror authorized age Dte - ISSUE
LUTA L: —
OFFICE COPY
X
it WA
F"Pil
t `VI� ."'- d'�t •F "�Y P '�'r 1� 4 `� ,�7{,IIW% '.P- \T' AZ] �":
A
R
-z-OW
—- ----------- -
No. 835
AT
Mkrafftrot �e ( ccu rttr�r l;;, ahs
Tity of Tupertin"
19P.ParImput of 749itilbing Insjurdlo"
This certificate issued pursuant to the requirements .
of. Section 307 of the
Uniform Building Code certifying that at the time of issuance this structure nm
in compliance with the various ordinances of the city regulating building
construction or use. For the following:
Use Classification Interior Improvernent
— Bldg. Permit No. 20567
Group B-2 Type Construction II-HR Use Zone Planned Development .
Ownerol'Building Testing 1 2 - 3 — Address 10123 N. Wolfe Road, Sp. 986aI
Building Address 10121 N-Wolfe Road Sp. 986 Locality Cupertino, California
By: JnP Vandevppr
Date: A13gll-it 20 199n
"1T ' Building Official 's '.............
A POST IN A CONSPICUOUS PLAcc
V1