19592APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro'ert Identification I
PERMIT NO.
Building Address: 119
10657 Larry Way
5 9 2
ners sine. Phone:
APPLICA I ION bU oMI I I A
Anna Miller 257-9394
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
po
�---� 3 [
Contractor's Name: sec. N.
Johnson Air 485350
BUILDING-ELECIRICA4PLUMBING-MILHAMCAL
CATEGORY
CONTROL I
Architect/Engineer. Lic. No:
.QTY r ELECTRIC PERMIT ,. FEE.
- BUILDING PERMIT INFO
Address:
PERhRTISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMreby ection em 70that lam Bcensefthcunder Buinessaonso(ChlorniC(le,and c-
inense I Sedfon force and dislon3ofthe Businessand Professions Code, and my
license is in full tonne and effect. �
License Clan _Lie#_485350
APPWANCESRESIDEN77AL
JOB DESCRQTION
'
PANELS
Date C mmiclor n n�'1 An i 1'
201-IODOAMN
ARCHITECT'S DECLARATION
I understand my plain shall be used as public records.
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ. Fr.
SIGNS ELECTRIC
Licensed Professional
SPEC L IRCUI
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP.M OR POLE
coietywhich requima permit tocomtmd, alter, Improve, demolish, o
following reason. (Section 7031.5, Business and Professions Code: AnyADM-
anystructure pdorto its issuance, alsorequires theapplicant forsuch pe
file a signed statement that he is licensed pursuant to the provisions
ES
CTRICsion
Contractor'. Licence, Law lChepter9(commencing with Section 700D) o
sion3 of the Business and Professions Code) or thathe is exempt therefro
VALUATION
the basis for the alleged exemption. Any violation ofSection 7(31.5
for a permit subjects theappcant to a civil penalty of na mofive
O SWf napplicant
RESID AL ELEC SQ.FT.
hundred dollars (A500).❑ 1, as owner of the property, or my employees with wages as the
STORIES
7YI'ECOKSIRUCTION
ompensatlon,wRldoRhe work andthestrocture is no[ Intended or offe
.in Soc.7014, Busineaand Profession Code: The Contractor`s Lt.doeanot
apply to an owner of property who builds orimpreves thereoOCC.
whodoessuch workhimself orthrough his own employees, provided that such
GROUP
,.
RES. UNITS
Improvements are not intended oroffered for sale. 11, however,thebullding or
OTAL:
improvement bsold within oneyearofcompletion, the owner -builder will hav
th,*rden of proving that he did not build or improve for purpose of sidi,17
u Las owner of the property, am elusively contracting w¢ licensed
contractors to construct the project (See. 7044, Business and Professions, Code:
QTY. PLUM I IT FEE
FLOODZONE
'
APN
PERMIT ISSU
The Contractor's License law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such plo)ects with a
cq➢t(�dorts) licensed pursuant tot he Contractors Limeae Law.
I—JI am exempt under Sec. B h P C for this recon
ALTER DRA WATER (EA)
FEE SUMMARY
BA IX FiAW T. DEVICE
DRAINS FLOOR RObF, AREA, COND.
SAMTARY Y N
RECEIPT # -
Owner Date
WORKMANCOMPENSATIONDECLARATION
f_11 hereby affirm that I have a certlfieste of consent to selifnsure, ora
cenifiate of Workers'Compewtion Insurance ora certified copy thereof(Sec.
38310, Lab C.I -1
PollcypJ 13375
Com any �L. Lam—
p1X'IVRES PER ,IAAF -
SCHOOLTAX Y_ N
RECEIPT #
GAS EA. SYSTEM-11NCA OUTLETS
-
PARK FIE Y N
RECEIPT #
GAS EA. SYSTIITI-0VER4(FA)
BUILDING DI VISION IBES
Certified copy herebyturmshed.
flCertified copy 6 lsfiled with the city Inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
_ -
PAID
CREASE TRAP
COMPENSATION INSURANCE
(fhissedion need not W completed if the permit is forone hundred dollan
SEWER SANITARY STORM FA 200F1'
Date Recel t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
($100)or less.)
I certify that in the performance of the work for which this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner so as to became subject to the
Workers Compensation Laws of California.Date
PAID
NEW RESIDENTIAL FLM& SQFT.
Applicant
NOTICE TO APPLICANT: If, after nuking thisCertificate e f Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recet t#
TOTAL:
BUILDING FEE
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked.
SEISMIC FEE
. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform
ance of the work for which this permit is Loved (Sec. 309'1, Civ. C.)
lenders Name -
Lender's Address
I mrtilythat I have read this applicationand slatethat theabove information
iscormd. l agreeto comply with all city and county ordinances and gate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE l�
�
PERMIT ISSUANCE Is
FEES PAID:
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, indemnity an d keep hartrdess the City of Cupertino
agalnsth ilitice,judgments,cost d expenses which may In anyway amus
Date Receipt#
ALTERORADDTOMECH.
AIR HANDLING UNIT (3010,006 CFM)
SUBTOTAL:
ago t al City bkco a) fth ming efth3spermn
��
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTAX
Signatureof Applicant/ ontractor 11/Det2e/g0—
EXHAUSTHCOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000BTU)
Will the applicant orfuture building occupant store or handle hazardous
Date Recef t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Healthand Safety Codi, Sen1on25532(a)?
❑ Yes - �] No
HEATING UNIT (OVER IWM BU)
TOTAL: ,
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
'�1��
yY4
P'Cc J 1990
Will the applicant or future building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Arca Air
Ouslily Management Dis�tjrict?
4haeread the hazardousomaterials requirements under Chapter 6.95of
BOILER -COMP OHP OR 100,0(10 BTU)
BOILER-COMP(OVER l00,0008TU)
the California Health k SafetyCode, Sections 75505,25533 and 25534.1
understand that if the building does not currently have a tenant, that it is my
NEWRFSIDEMIALMECH. - ' SQ.FF.
- responsibility to notify the occupant of the requirements which must be met
prior to issuance a a Certificate of Occupancy.
##ss
(nsj}R at
Nta,L v6 iur"tM,
a
//
SSUEDBYN.
Owner or authorized agent Date
TOTAL:
OFFICE COPY