00010072APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 415(")/00-72N,
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
'- , , BUILDINGTROJEQTQDENTIFICATION' ;'V, 77
PERMIT NO.
BUILDING ADDRESS:
10112, �AMINo VISTA•'
SANITARY NO.
/
APPLICATION SUBMITTAL DATE
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WNER'S NAME: PHONE:
"RALMIZA TatuT
CONTRACTOR'S NAME: LIC NO:
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WC
❑
CONTROL#
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iiCCHI'I_EC'PHNGINEER: LIC NO:
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ADDRESS:
CONTACT:, rHONE',
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❑ Consultant Fees Paid by Applicant (Initial)
I't.; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
1 hereby 1 am licensed coder f Chapter 9 (commencingQTY
provisions n
with Sectioe7000)af Dmrsimm3 ofthe Disieessand Pmfessiens Ced,,and my licensees
in full punched effect. -
License Class Lie.#
Date Contain,
t s
'! " ' EUEdCTBIG PERMIT` i t I ,jr PEE
r'•
JOB DESCRIPTION
RESIDENTIAL:
❑ SCOWL r ❑ KITCHEN REMODEL
In
'ADDITION ❑PLUMBING RE -PIPE
❑STRUCTURAL
MODIFICATION
r] INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
❑ BATH REMODEIcREPAIR []DEMOLITION
❑ OTHER
'
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT "S DECLARATION❑MULTI-UNIT
1 understandmy plans shall be used as public records
PANELS
UPTO200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
fallowing reams. (Secdon ]113 L5, Business and Professions Code: Any city orcounty
Which requires a permit to consumer, alcor, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions ofthe Commeler's License Law (Chapter9
(commencing with Section 9000) of Division 3 ofthe Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant me civil penalty of
not more than five hundred dollars ($500).
01, as owner oftheproperty, or my employees with wages as their sole compensation,
will do the work, and the stroatme is not intended mirfficed tensile (Sec. 90a4. Business
and Professions Cede: The Cunkm e License Low does nor apply to as owner of
prepeny who Faults or improves thereon, and who dues such work himself or through
his own employees, provided that such improvements arc not intended or offered for
sale
sale. If, however, the building or improvement is sold within one year ofcompletion,tha
mwme M1'Ide will the burden fp gthtl did not build improvef pur-
pose f l)
❑Ia of the property, a exclusivelycontracting with dcontractorst
carsomache p) t (Sec 7044 Ba,mass and Purfie,ears C d) Unt, Conn..,, Li
cause Law dnot t t property h builds o p e d
echecontractsfor suchpjmtsw Nemntrmmds)Rensul pursuanto theContractors
License Law.
❑ lam exempt under Sec ,B&PCfor this reacm
201-IOOf1AMP5
OVER Has) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIUMISC.
TEMP. METER OR POLE INST.
9
COMMERCIAL,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
(-]TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIX9'USES
( NEW RES]
� rf
SQ. FT. FLOOR AREA
4L�1
$ISQ. PT.
-- aYlb
'Y 1„ll U D AL
J�
I
FEB 18 2000
s 't
} PLUMBING PERMIT I FE�y}t„
QYr.tj 4 l1_U - t }
PERMIT ISSUAN [w<w
ALTER - DRAIN & VENT - WATER (E 1)
tract Date
// oO VALUATION
^
— p$�$1"1 'V llll N
B11--_(6
,
'
}YORKER'S COMPENSATION DECLARATION
I hereby affirm ander penalty of perjury one of the following declarations:
,❑ l have ad will maintain o CeniOcate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance mf the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700of t he labor Code, for he funfmmucoeof the work far whichthis permit is issued.
My Worker's Compensation Insurance rather and Policy number are:
ca
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forms, hundred dollars($ 103)
orlcce)
I certify that in the performance nflhe work for which this permit is lesued. I shall
nor employ any person in any manner so as to become subject m the Workers' Compen-
sation Laws of California. Data
Applicant
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, COND.
'�—STORE35
OCGGROUPI'
-TYPP' N59'RUCTION
�APN
-I
FIXTURES - PER TRAP
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
GAS -BA. SYSTEM -OVER 4(EA)
GREASEIINDUSTRL WASTE INTERCEPTOR
'sg �BUIL+,DFNG DIVISIONTEESa 9 k s+ q t
GREASE'I'RAP
PLANCHECK PEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENTIELECfR
GRADING FEE
NOTICE TO APPLICANT', If, after making this Cromficam of Exemptinm, you should
became subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby offirm Nin there is a construction lending agency for the performance of
the work for which this permit is Issued (Sec. 3099, Civ, C.)
Lender's Name
WATER SYSTENY BEATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
Date Receipt#
TOTAL:
Lenders Address
1 cesti fy that Ihave read thisapplication tlnit that the informationsc
lagree m comply with all city and c ry ordinances and telrelatingto
hulldingeonswelan and hereby authorize represermives ofthis e'tye emaupoe the
above-mantioned property for inspection purposes.-
(We) agree to save, indemnify and keep harmless the City of Cuper im against
liabilities.judgments, cosh and expencec which may in any way accrue against said City
in asequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
- TOTAL:
BUILDING PEE
,tIF �s�FEE'tI
QTY teMT
},rest
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC PEE
AI:fER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (1010.000 CFM))
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature ofAppleart Oontmaor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sere or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Satdy
Coda Section 25532(x)'! -
El Val 7 N
Will the applicant orfurore defined occupant use equipment tQuofdeviceswhich
Dust hamrdnus air ttmominnnG as defined by the Bay Area Air Quality Management
District'
F-1 Ida, ON.
I have read the harandoos materials renuirem,ms under Chapter 6.95 of the Coli-
fomia Healgdoes &tSafetycraw Code, Sections 25505, 25533 and 25534.1 endarnacas that if the
building does not ccmn0y haves tenant, that o is ua responsibility e notify case reception
of the requirements which must be mot priono issuance ata Certificate of Occupancy.
EXHAUST HOOD ONMUCT)
HOUSING MITIGATION FEE
HEATING ON I'T(To 100,000 BTU)
HEATING UNIT (OVER 100,000 WITH
PAID
--
VENTILATION PAN (SINGER RESID)
Date Be.,,[
BOILER- COMP QHP OR I OQ000 BTU)
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
�—� f0
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAI. MBCH. SQ. Fr.
Owner or authorized agent Date
TOTAL',
OFFICE