21106 (2)0
•
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY ok o 7-
Building Project Wentlf"tlov
Building Address:
0
PERMIT NO.
2110
6,
r ` C_%&av one
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
10 -i "g 0
canto 'a N. Lc
BUTLDING-ELECIRICALPLUMBING-WJZHAMCAL
CATEGORY
CONTROLa
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1 1 . C � U(�Ltc N.
Q ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
.
Address
LOBS
PERMITISSUANCE
LICENSED CONTRACTOR'S
u oder ,DECLARATION
I he,affirm thatlam lkensedundrr provisions of Chapter (.wntr�m
I a
AI'1'LIANCFSRF9DFMIAL
)08 DE19CRIPTION
Iogwlth Scction7000)of Dbrtdoe0 ofthe Bualnaa and l'rq{gad.Code, and
Ism. 41. (u- and &Left 5 /
Lk LbI
Date �Cantnnor
PANES
UP TO 2DD ANIPS
T�'' I '1
� r UW L.
F D
201-IODO AMPS
ARCHITECTS E LARATION
I undenund my,plans shag be used u public records
OVERIODOAIAM
SQ. Fr. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
(•�.J
SPEZIALCIRCUI'r/M1.9C
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt a C.ntrxlor's Llcerue Law the
I y IH.
TEMP.MEfERORIKN.E INS,.
shots dr
colbwwhiclaing rot. (Ses.per at to Rasmus and Pmporm, Coda:Mydtyor
muvtywhRh rcqubes pemdt alter,ImpmK,
� a
`�- /��•`�
forsuch. eorepair
any atsined tatemePrior to ltnbeuancIs abo reed pursuant to the lxsuchpemdt a
e,c 6orequ
fileCo a signed statement that he L IkevM purauanw of the
POWER DEVICES
S MhflNG POOL ELECTRIC
OL LETSSWITCHES-FIXTURES
Se do 70DO)
with
Contractor's Gcerue Law (Chapter9(comnrndng he Is exempt 700D)of qW-
don 3 vfthe 8udnev and Prdmbm Cole) .,that hely exempt 1hereGamand
the basis far the alleged exemption- Any vt.latbn of Sectkan 70315 by any
appflontforapermltsubjedstheappbcaattoadvilpenakydnatnnrethan
VALUATI�
_l qi
( .]
NEW RESIDENTIAL ELPCIR SQFI.
five, hundred dollars MW.
F-1 1, as owner of tha property, or my employees with wagen as their sole
STORIES
TYPE CONSIRUCHON
! O
penvtlw will do the work, and the structure Is not Intended or offend for
sale (Sec- 7004, Business and Pmfesbro Cade: The Covtract.e. IJceme Law
TOT 0
dxa net apply to an owner of pmperty who butts or Improves thereon, and
who doeaeuchwork hlmxBmthwgh hi,ownempbyees, p.1ded thataach
Improvements mes am not Intended.,.!(ered fxsale. If, however, the Wilx ing
OCC GROUP
RES UNTIB
Improvement usot within oneyurofcompidbr,th, owner-bullderwW have
t ,den of proing tm that he aWild or Improve !« purpme ofsals.).
I11, as owner of the property, am exchu uely contracting whh IberuM
mtrn (Se nactoto construct the pmjed(S7004, Busies." Pnrfeabm Code:
QTY. PLUMBING PERMIT FEE
FLOOD7DNE
APN
PFRMITL4UANCE
{{
The Comnadols Llcerm Law dm nn apply to an owner of property who
bunds or Imprwea thereon, and who contracts for such pT)mU with a
licensed pursuant to the Contractors Lka r se Law.
LJ 1 am exempt under Sec B & P C for this reason
ALTER -DRAIN& VENT- WATER (EA)
.
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
r'o US I DE FEES
DRAINS FLOOR ROOF, AREA, CONE).
SANITARY YIiCCFIIrf
Owner Date
WORIQAAN COMPENSATION DECLARATION
❑1 hereby alflmn Wuse t I fa certificate of coruent to self -Insure, or •
certificate of Worken'Coarpensarfor Insurance or a co"Ied copy themrf(Sec.
3 ,lab C)
PIXIlIRFB I'Et IR,V'
SCEIOOL TAX Y_ N_
RFCFL7I
GAS FA. SYSTEM -1 INC4 OUTLETS
PARKFEE Y N
RQ'm'1'
Cray /'
Po�mp�
GAS FA. SYS OVM4(FA)
BUILDING DI V ISION FEES
I Ccnlfied copy is hereby fumtshed.
r CertNed copy as filed with the city Inspection div Won.
GREASE/INDUSIRL WASIEINTFRCFTIOR
P K FEE
GRIEA''�TRAP
CERTIFICATE OF FXEIAPTION FROM WORKERS'
INSURANCE
NSURANCE
(ITL section need nn be completedSUR isfat ora hundred dollen
PAID
a Reuel t# raj=
SEWER -SANITARY -STORM EA IO�T
I-ffATese w/vFxr/FirrrR
ENER FEE Y N
(MMorless.)WATER
Icertifythatlnthepedormanceofthew kforwWl Wspe,mhL ed,
WATER SYSTEM/TREATI NG
1 sha8 oat employ any penin In any owner so as to become subject to the
Date
PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
NOTICE TO APPLICANT: If, after nuking this Certificate of Exemption, you
ahmldbeco subjectiothe Workers Camperuat pmvis mofthe Labor
doomed uroloed, thtvhh comply with such proWsbm arNis pemdt andlbe
deemed revoked.
CONSTRUCTION LENDING AGENCY
Date Reoei t#
QBUILDING
TAL:
FEE Q s
—
SEISMIC FEE
Ihemaffirm thercisamrutrodlon lmdingagenry for the pedomm
an m oftheworkmrwhlchthbpemdlhLssued(Bee3 ,CW.C.)
Icnder: Name
Lender'.Add.
I certifythnt I have read this appBextbnand Ramthat theabove Information
LcorrcR. lagreetocomplywlthaH tyaMowntyordlnav ddatelaws
TOTAL:
Q
ELECTRIC FEE 6
-
PLUMBING3 77 s 10
MECHANICAL
FEES PAID:
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE (fb
relating to building construction, and hereby authorise representatives of this
city to enter upon the above-mentioned property for inspection pu rposes.
(We) as. tosave, Indemnify an d keep hadea the City of Cupertino
against BabWties menta, andex wM yin anywayamue
q
Date Raci t# �lL 169
ALTERORADDTOMBCEL
AIR IiANDI.ING UNIT tT010.000 CEM)
SUBTOTAL
against as voft h on permtL
fD
AIR HANDLING UNIT (OVER 10,000CFhO
CONSTRUCTION TAX
FxEIALST I-IooD (w/ol)cI)
CONSTRU T P
L
n afA m/cantranor e
HAZARDOUS MATERIALS DISCLOSUR
HEATING UMT(TO 100,000 BTU)
Wllltheappli ntorloure Wlldbgo.mpantstomorhandeh cus
craterisl as defined by the CupeAine MuNdpal Code, Chapter 9.11, and the
Eleahh andSafety Code Section 25532037
❑ Yes M No
Will the applicant or how re building occupant use equipment or devim
_
Date Rcccf t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE! f.y�ja[l
whkhcmit havrdousair contaminant, as defined by the Bay Are. Air
Qu Lily M1fanagement District?
Y "°
4h veread het yCode, Se tions 2menbunder Chapte4.1 of
Rha Gllfomtaat if the bSafety Code,, Sections Zi5Q5,2 aternd25J4.]
underwndslut if the building docs not mrrently have aterunL that ltisrtry
PAA ,t
T
YII 1 , 1991
APR
BOILER -COMP OFE'DR 100,000 BT11)
BO ER -COMP OVER IW,000 BTU)
NEW RESIDENTIAL MECH. SQFr
resporulbflIty to nalfy the occupant of the retpainmenu which moat W met
prior to tau.. of. Certificate of Occupancy.
nnttww r1s
r O
(s�a'�s�l�,`//f.1yg..��..���
ISSUEDBI'^v"v �
Owner or authcr,od agent Date
pro
TOTAL s 2
OFFICE COPY