19838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Prdect Identification PERMITN0.
Building Add
reae: {� 19838
I ^^ /�n
10100 VISTA Qrl% �IC" I l9J l�J{ l'/(j8
neve lire: /'A,, Phone:
FeTaC
m rZDrA 252 u33 CITY OF CUPERTINO-BUILDING DIVISION �`ry��
co�
Mo
Llo.No: APPLICATION /PERMIT l
.JG�t'�S SAZ95'5' BUILDING-ELECTRICAL-PLUMBINC-MECHANICAL CATEGORY CONTROLM
Ar .mund/Engineer Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
PERhRTISSUANCE 1:1 El ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcensed under provisions of Chapter9 Ecturnmeme. APPLIANCESRESIDENIAL JOB DESCRIPTION
Ingwith Section 7000)o1 Dlvlslon3ofths Buslneasand ProfemlomC-ode,and m
license is in fiWorce and effect. �.^ PANELS
License Clam— LION S 7^9SJ _I ,♦� ,
Date3^ LIF.# .m u
ARCHITE ECLARATION 201-1000AMPS
XZ Iunde.tand myplamshallbeueed apubllcrecmds. OVER LOBO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
0; Lkcnsed Profemb.l SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
rn] SPECIAL CIRCUIT/MISC
ZE' owing of@mSectin7MI.5,exempt from the ContnctsionsCLicense Law fee the
following region.(Section 7Rp1.5,Business and Professions Code:My city or
D ti TEMP.METIER OR POLE!NST.
p� countywhlch rcqulresa perMttoconstroct,strep lmprovc,dertolbh,orrepalr.
anyslm=m ptlor/e Its Issuance,also requlreathe applicant Eunuch permit to POWERDEVICES
µ file a signed statement that he Is licensed pursuant to the provisions of the
µ Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
HOS don3oflheBusineeaandPro(embneCode)orthethebexempttherefmmand % VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
0OUTLETSSNOTCMSFIXTURFS /.-. �o
,5 spplicantfor a permit subjects theapplkanna
t to a civil pelty of not more than lJ
Q five hundred della.(5500). _SQ.• STORIES TYPECONSTRUCTION
J u. NEW RESIDENTIAL ELECTR IT.
Ll �n ❑I,aowner ll the property,orho emp)oyemwith
ended or offered
compensation,w01 mus i work,and thestmcture b not Intended or offered for
D sale(Sec apply B.to alnowandf property
Code:The Contraor improves
License Lad
5$
does mtapplytruch torn owner ofproughhisonemoymproovided thereon,and OCC.GROUP RES.UNITS
whodwaentsam khlmeelf edoroogh hisown employees,providedthat ing or
improvementsarenot intendedoero(co (orale.If, owner,p deer ldtgve TOTAL:
Improvement teold wlihinoncycarofcomplMioRlhe ownervbullderwlll have
t rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE F(.00MNZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064 Ruslnem act Pro(emba Code:
The Cont.ctoes License law does not apply to im owner of property who ALTER-DRAIN AVENT-WATER(FA)
builds or Improv.thereon,and who contracts for such pkujees with
ogR�actor(r)licensed pursuant to the Contractors Limn.Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
LI I am exempt under Sec B h P C for thb regionOUTSIDEFEES
Owner pate DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION❑ FIXTURES PER TRAP SCHOOL TAX Y_ N I hereby affirm that 1 have•mrtlBale of consent to salt-Inure,ora
certlfiateo(Workers'Compcv tlonlnsuranmoraudifledmpythemof(Sec. RECEIPT N
PARK FEE Y N
I / 3800,Iib CJ GAS EA.SYSTEM-1 WC.4 OUTLEES
Polley at RECECAS EA.SYSTEM-OVER 4(FA) DINC DI p
Com any BUILDING DIVISION FEES
Certified copy b hereby furnished. CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed withh the
e cicity inspection division.
CERTIFICATE OF IXEM PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA N10F1• Date Recd t#
Qhlsaectlon need not becompltcd If the permit b fortune hundred della.
($100)orlem.) WATER HEATER W/VENT/0-ECTR ENERGYFEE Y N
I certify that in the pertormenceofthe work forwhich this permit la timed, —
I that]not employ any person In any manner n an to become subject to the WATER SYSTEM/TREATING
O
Workers'Compenalion Laws of California. Date PAID
-
z
Applicant NEWRESIDENTTALPLMB. SQ.FT. Date Recel t#
Z NOTICE TO APPLICANT:ILaflcr ma king this Certificate of
Exempllon,you
should become subjeet/o the Worker'Compensation provbloa o(the Laborir TOTAL:
W Code,you.,I forthwith comply With such provisions mthb permit shall be B N E
deemed revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirmthxt them is a construction lending agency for the perform- ELECTRICFEE'
Z anceoflhe Workferwhlch this permit is bsued(Sec.W97,CIv.C.) TOTAL:
U O Lender.Nim, PLUMBING FEE
LL. Lender.Addrcu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lad]fythatlluvemadthbappBationand Matethatthcrbovelnf..tiun
S Bcomid.I agree to comply With all tltyand county ordinances and Mate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorlu representatives of this
F- Z city to enter upon the above-mi,mloned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the Cityof Cupertino Date Revel t#
O agalnst liabilities,Judgment•mMund exper.which may In any way accrue AIR HANDLING UNIT(TO IO,OW CFM) SU13TOTAL•
against said City in consequ era of the Bating of this permit.
AIR HANDLING UNIT(OVER I QW0 CFM) CONSTRUCTION TAX
Signature of App]lant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cu Fortino Municipal Code,Chapter 9.12 and the
Health and SafWe Scalm,255324)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
I—I Yes 7d 1 Na
_ emit
appllantor tum buildingocmpandby the Bay Area devkea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eMt hazardous air contactant ae defined by the Bay Arca Air
Quality Mateaggirent DislM07 BOILER-COMP OHP OR IW.OfD BTU)
4 Yc No
ha'iereadthe haze ws materials requlrcmcnt under Chapter 6.95 of BOR-EA-COMP(OVQt 100,OBOBN)
the CallfomWliealih&Sof ode,Sections 7550.5,25533.rd25534.1
understand that If the n oea mat mrrcnily hit
nq that it Is my NEW RESIDENTIAL MECSI. SQ.IT.
imperial ity ton th cupant of the re hlch at be met
r uarm
Owner -auih t d agent Date
TOTAL: ISSUEDBY:
3-4' 98
OFFICE COPY