20967 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL P0114T PEN ONLY
Building Address:Building Pro est Identification- PEkMITNO. -
as
11087 Linda Vista 20967 0 9 16
wners m: oner A
PPLJCAUON SUBMII IAL DAM
John H. Peters 252-4534 CITY OF CUPERTINO-BUILDING DIVISION
contractorsNamer Ltc,NAPPLICATION / PERMIT 7
A./E:nc. Furnace Co . 170O40'
Architect/Engineer. Lk.No: BUILDLNC ELECTRICAL PLUMBING-MECHANICAL CATEGORY. CONTROL k
•
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1712 Stone Ave . ��i PLUMB
PERlwnssuaNCE
LICENSED CONTRACTOR'S DECLARATION ❑ , El El
Ihereby.fit.that l son licensed under provielonao(Chapter 9(..no APPLIANCES-RESIDENTIAL JOB DESC ON
Ing with Section 7000).!Division 3ofthe Business and ProfeasionsCode,and my
licenxlelnfull�o�c5 antl q((�ct PANELS
License Clam 1:4.i (,Icd Date 8 ^. Contractor {—OIN •. eel2DO .
`r".L O'"9�CHITECI'SDiCLARATION 201'1000 AMPS
ri pZO I understand mypiarsshal be used as public records. OVER 1000AMPS 00 AREA g/SQ.FT.
[Iid�dRiBi..l Uy Licensed Professional SIGNSELECTRICAL
6 FI'du OWNER-BUILDER DECLARATION
I herebyafflrmthat l am exempt from the Contractor'.License Law for the S['ECIAL CIItCUfr/MLSC
D 9�qq pp following reason.(Section 7031.5,Bu.iness and Profession.Code:Any city or TEMP.METER ORPOLE INST.
P4a countywhichmquresapermitw-.troa,alter,impmve,demn h,orrepalr -
.� any strocture prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provlsloro of the
3 w�, Contractor's License law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING]i70L ELECTRIC
�Oa
elan of the Business and Professions Cod.)arth.t he bexempt therefromand VALUA71ON
6 tM bnsb(or the alleged exemption. Any Wolatlon of S¢ttlon 7031.5 by any OUTLETS-SWITCHE -FIXTURES
O apptlrant(ora permit subjeciethe appilcant-.°civil pemlly.f pot mo.the.
five hundred dollam($500), 1 NEW RESIDENTIAL ELECTR
�i ❑I,ea owner of the properly,or rr7'employers with wages as their sok —SQ.FT. STORIES TYPECONSTRUCTION
compeneatlon,wBldothework andiheatrutture toot Intended or offered for
O .ale(Sec 7064,Buotnesa and Pro(enloro Code:The C.ntractole Llcerse Law
$ does not apply to an owner ofproperty who WIWe or improves therroN and -OCC.GROUP RES.UNTfS
whodoneuchworkhimsel(orthrough hlsownemplayee.,providedthatsuch _
Improvement are not intended proffered(or sale.If,howevep thebulldingor TOTAL:
Improvementbeoidwithinoneyearo(completbo,the owner-bullderwillhave ,
tf e�urden.!issuing that he did not bu0d or improvefrn purpose.fit.). QTY, PLUMBING-PERMIT FEE FIpp11 LINE ppN
a
u L as owner of the property,em exclusively contracting with licensed PERMIT ISSUANCE
rontractore to rorstmct the project(Ser.7094,Busters ami Profeas..Code: -
The Contractor's License law don not apply to an owner of property who WATER(EA)
Wilda or improves nt
thereon, and who coract° for such ptvjALTER-DRAIN-DRAIN&VENT-
ecta with a
dattor(a)licensed punmant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE .FEE SUMMARY
I am exempt under Sec. B &P C for this reason
OUTSID
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLARATION - RECEPTN
❑R hereby affli m that I have a certificate of consent to self-insure,or FIXTURES PER TRAPSCHOOL TAX � Y N_
certificate ofwodu,''Comper ea0on I........difted copythereof(Sec. S RECEIPT X
3800 La
PoRb C.) WC 50 7829045 GAFA,SYSTEM-1 INCA OUTLETS PARKIBE Y— N_
cT• - RECEIPT N
Com any GAS P.A.SYSTEM-OVER 4IRA) BUILDING DIVISION FEES
Certified copy he furnished.thcity GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Com
copy b filed with the city Impaction division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY5CORM EA 200FT Date Recei t#
Qhb section need not becompleted Bibs permit b(Drone hundred dollars
($t00)orleas.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
udlnot-haththe person
mannerhe so et to
this pemdtbbothesued, —
I shag not employ any Laws In any manner se u to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of CaB(amla.Date PAID
O Z Applicant '
Z 0 NOTTCETOAPPLICANT:If,ager making lhb Certificate.(Exemption,you NEW RESIDENTIAL P[.MB. SQFT. DateRecei NI
should become subject to the Workers'Compenatkm proWlons ofthe Labor TGTAG
WLo Code,you=at forthwith comply with such provisions orthb permit ahallbe
> deemed revoked. BUILDING
CL CONSTRUCTION LENDINGAGENCY SEISMIC FEE -
Iherebyaffirm that there b a costiuctlon lending agency for the perform- TOTAL ELECTRIC FEE
M Z ance ofthe workforwhkhthb permit b inued(Sec.3097,CIv.C.)
0 — Lender's No
PLUMBING FEE
LL t— Lander§Address QTY. ' MECHANICAL PERMIT FEE MECHANICAL PEE ,
O W s I certifythatl have readthbappU.ti.n.ndsaWthattheaboveinformation
C rormR.lagreeto romplywithellcityand rountyordinanrneand nate lawn 1 PERMI7155UANCE FEES PAID:
} W relating to building construction,and hereby authotce representatives ofthb
)— dtyto enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z
Z (We)agree to save,Indemnify and keep Date ReceiIii harmless the City of Cupertino P
agairstllab tits,judgment,costsand expenses which may In anywayamme AIR HANDLING UNIT ITO I0,0D0 CFM) SUBTOTAL:
again, dC In consequence ofthe granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
v:i0am _
Igmture p t/ ontr r ""IKie.'-` EXHAUST HOOD M/Duca. CONSTRUCTION TAX PAID:
HA7AR US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
material A defined by the Cupertino Municipal Code,Chapter 9.12,and the -
HealmandSafelyCode SacB.n25532(a)7 - HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yn i XI No
n
Illtheapplinnt o-ruture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which em t hazardous air contaminants as defined by the Bay Area Air ��
. ' Quality Management District? BOILER-COMP OHP OR 100,DM BTU)
qYea IV No
have read the haze Due materlab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 LIM
the Califemla Health&Safety Code,Section 25505,25533 and 25534.]' APR �Q�,f
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEIN. SQ.FT s�q.((
respo "Ity to notify the occupant of the requirement'which must be met
'Prio to he anceofa lOcee Occupancy. U
nen thorized:agent — R .DU ISSUE
TOTAL:
OFFICE COPY