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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING -MECHANICAL
APPLICATION/PERMIT
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
PERMIT NO'28282 L ^ 8 Z V Z
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
%
UNIT # LOT #
OWNFSdNAME: PHONE:
CO RAC OR'S AME: LIC NO:
L� -O
IL
N/C
0
CONTROL #
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMIT ISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions Code, and my license is in
full force and e 2 C
License C_la�ssrLic. # o"6SI
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
UP TO 200 AMPS
Dale S Contractor
ARCHITECTS D CLARATION 1W.({J,-r-n
I understand my plans shall be used as public records.
201 - 1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
$/S. FT.
Q
SIGNS ELECTRICAL
Licensed Professional -
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
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 file a signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
-�
OUTLETS -SWITCHES - FIXTURES
not more than five hundred dollars ($500).
[IS L as owner ofthe property, or my employees with wages as their sole compensation,
NEW RESIDENTIAL ELECTR _SQ.FT.
Q
STORIES
TYPE CONSTRUCTION
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY, PLUMBING PERMIT FEE
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
FLOOD ZONE
APN
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License taw does not apply to an owner of property who builds or improves thereon, and
PERMIT ISSUANCE
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. B & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOOR, ROOF, AREA, GOND.
SCHOOL TAX Y N
iereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers' Compensation Insurance ora certified copy ereof (Sec. 3800, Lab C.) which
RECEIPT #
FIXTURES - PER .CRAP
PARK FEE Y N
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
covers all emp�' ythis pe 1 -�
Policy # / ,?
RECEIPT #
BUILDING DIVISION FEES
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
COm�ny
(Ce ified copy is hereby furnished.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING FEE
ertified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
.•-3`EW$R SFt'1CTARY"`STORM EA. 200FT.
ENERGY FEE
(This section need not be completed if the permit is for one hundFelll>�lars ($100.}
or less.) '
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner �o as to -become subject to the Workers'
Compensation Laws of California. Date t.,, t �� a 2 A I
WATER HEATER W/VENT'kLECTR
PAID
Date Receipt #
TE S M/fREATIN%1'r
ApplicantT�r
SI AL PLMB. SQ. FT.
T
NOTICE TO APPLICANT: If, after making this Certift to of xem ti y s d
become subject to the Worker's Compensatibn provision e ab e ut
forthwith comply with such provisions or thjs permit shite re 1
/ oel
BUILDING FEE
i
TOTAL:
SEISMIC FEE
CONSTRUCTION BENDING AGENT w �
I hereby affirm that there is a construction lemg agen
the work for which this permit is issued (S 3097iy, C.)
ELECTRIC FEEt
Lender's Name
•y -
_ - = fie? � � "AL PERMIT FEE
PLUMBING FEE
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liab' i es,judgments, costs and expenses w 'ch may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
in equence of the granti is i
P
AIR HANDLING UNIT (OVER 10.000 CFM)
Signature of Applicant/Contract Date
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
HEATING UNIT (OVER 100,000 BTU)
IRTAV
JqD
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?()
0 Yes O --o
NISSUANCE
VENTILATION FAN (SINGLE RESID)
DATE
Will the applicant orfuturebuildin ccupantuseequipment ordevices which emit
hazardous air contaminants as def by the Bay Area Air Quality Management
District?
❑ Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the builifiV does not currently have a tenant, that it is my responsibility to notify the
BOILER -COMP (3HP OR 100,000 BTU)
k:--'
Arr
V `' `
66AA i �g��
'�' '-' U_ C ,
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ. FT.
occur f he require is which mu t7pri issuance of a Certificate of
/b�.t,riet
Occul t
'��21ri
ISSUED BY:
Owner authorized agent Date
TOTAL:
OFFICE
7648 Xewcastle Dr.
CITY OF SAN JOSE BUILDING DEPARTMENT
PLICATION FOR!JDING PERMIT
LL
Date. t
--•----------•--------------
9-&-'z--- Permit No. -7,
---------- --------------
Application is hereby made for a permit to ----------------- -----------------------
a ------- / ---story, Type---------- --------------- ------ ------
Building
A
------
to be occupied only as --- / ---------
f �
in accordance with Plans, Specifications and. pr6 -plaf filOct, rewif
d
i.
Estimated Value of Improvements, ------------
It is hereby agreed that the requirements of the San Jose Building and Zoning Ordinances and all other
laws applicable to the construction, location, and use of buildings within the City of San Jose, will be
complied with.
I certify that in the performance of the work for which this permit is issued I shall not employ any per.
son in any manner so as to violate the workmen's compensation laws of California.
16155 Greenwood Lane.'
JORNSOR Ho Er M
Owner I ----------- - ------ Address ----------------
- --- - ------- -
16155 Gree Woo -1-3
By 4 2 -------- ------- ------ --------- Address --- -------------- ------------ ------ q z
- --- ------ ---- aly -- - -----------
Agent Los Gatos, California
Form 280-1
RECORD OF INSPECTION
4.
Foun a
aiihe��•
•
F 2 --------------------- --------
✓
cco r. " "
-------------- Finish
................
c
E Gid 9 C,
7648 New Castle Dr. q
Building Permit Confirmed ❑
Not Required __Q_
CITY OF SAN JOSE BUILDING DEPARTMENT
APPLICATION FOR PLUMBING and/or GAS PIPING PERMIT
7—r�—
Date _ -------------- _------- ----------------- ------ 19.7 Permit No..---1D1�-V-----------------------' 6
The undersigned herU""w
spector of the City of San Jose
for a permit to install pthe reverse side.
Exemption from requntractor's License is hereby claimed
by undersigned: tatement filed Q-2 F/ 2 3 ,
Undersigned attests that his State of Californiapfr
or'sLicense _ •C
is in full force and effect and properly authorizes thitio ,
San Jose City Business License #
I certify that in the performance of the work for which this permit is issued I s ll not employ
any person in any manner so as to violafe the workmen's compensation laws of California.
OWNER VA L_C O
ADDRESS ?6 `f o�F A,&4-'C'A S -7 -4 -CZ Z? Lot No.
USE OF BUILDING—r"-
280-30
UILDING rieo-ao Signed =` ---------
7648 -Few Castle Dr. Ace