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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION
APPLICATION%PERMIT
BUILDING - ELECTRICAL.
PLUMBING - MECHANICAL,
BUILDING PROJECT' IDENTIFICATION
PERMIT NO. 28951 ^ ^ I
y8 �9 5 11
NUILDINGADDRESS:
2
&.XvIS.
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SANITARY NO.
APPLICATION SUBMITTAL DAT
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O EWJJ R'SpW.1'
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ONE:
CO ACTOR'SN LIC NO:
NIC
❑
CONTROL#
'RCHIT-CT/ENGINEER: IdCNO:
ADDRESS:
CONTACT:
PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial) NLUc
I berth affirm that 1 am licensed under aro urs cf Chapter 9 (commencing
y p water m g
QTY
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
PERMITISSUANCE
'I
wish Secnian]glo)of Division3nfthe Buxiness and Professions Codgandmylicensels
in full force a" effect.
RESIDENTIAL,
❑SFDWL CHF.N REMODEL
APPLIANCES -RESIDENTIAL
License Class Lia#
Date Connector
DDITION MBING RE -PIPE
MULTI -UNIT El STRUCTURAL
MODIFICATION
RIOR [I CHIMNEY REPAIR
> 1 PROVEMENT
ARCHITECTS DECLARATION
I understand my plans shall be used os public records
- PANELS
UPTO 200 AMPS
Licensed Professional
201-1000AMPS
OWNER-RUILDERDECLARATION
xpt from the Cmarma Licse Law fur the
1 hereby affirm that I um eemis en
following recom. (Section 7031.5. Business bad Professions Cale: Any city or county
ElBATH REMODELREPAIR [I DEMOLITION
❑ OTHER
OVER IMIAMPS
SIGNS ELECTRICAL
which requires a permit to constrict, alter, improve, demolish, or repair any structure
SPECIAL CIRCUITIMISC.
'mono its issuance, alsono,niestheapplicant fm such permit to file a signed amtemetn
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
TEMP. MITER OR POLE INST
COMMERCIAL:
(commencing with Section]IIf10)of Division 3a1' the Busmassand Professions Code)or
that he is In empt therefrom and the basis for the alleged esemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mare then five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is norintended or offered for sole (Sec. 7044, Business
POWER DEVICES
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
and Professions Code: The Contractors License Law does not apply to m owner of
OUTLETS -SWITCHES -FIXTURES
NE ENTIAL ELECTR SQ PT.
Property who builds or improves iher:on, and who docs such work himself or through
his own employees, provided the, such improvements me not imendcd or offcred far
sale. If. however be building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving the he did not build or improve for par-
I owner Of rhe pmpeny, am exclusively am mvding with licensed comecmes Or
SQ. PT, FLOOR AREA $/$Q. FT.
�O t 0—^
J`
A
.
all jact (Sec. 7016. Business end Professions Cale:) The Cnntracturs Li -
muse Law does not apply to an owner of property who builds or improves thereon, and
QTY,
PLU G PE IT
FEE
who contracts for such Projects with a commands) licensed pursuant to the Contactors
rm
PERM CE
License Low.
❑ am cv In under Sec. . B & P C for this reason
ALTER-DRAT-WATER(EA)
^w' VALUATION
D O
mer Dme
WORKER'S COMPENSATION DECLARATION
BACK FLOW PRO E . CE
Ihereby afflrm under penalty of perjury one of Ne following declarations:
V
"`JJJ V
V eSqA
13 I have and will maintains Catifice,eaf Consent m self-imure for Worker's Co.,.-
sabots, as provided for by Section 37M Of the Labor Cade, for Ne perforn.ce, of Ne
DRAINS- FLOOR, ROOF, AREA, COND.
STORIMO
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES - PER TRAP
❑ 1 have end will mainein Workers COmpenetian Insurance, as required by Section
37M of the Labor Csnle. for the perfonnmce of the work for which this permit is issued.
OCC. GROUP
APN
GAS- EA. SYSTEM. INC. 4 OUTLII
My Workers Compensation insurance carrier and Policy number art:
Cartier. Policy No.:
11
GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPT ION FROM WORKERS
COMPENSATION INSURANCE
GRFASEIINDUSTRL WASTC INTERCEPTOR
BUILDING D ISION FEES
(Thissmrion need not he compined if the permit is for one hundred dollars ($100)
or less.)
GRFASETRAP
PLANCHECK FEE �,!
I cenifythat in doe perfommame oftbe work far which this permit is issued, l shall
nut employ any person in any manner ea as to became subject to the Workers' Cons n-
SEWER -SANITARY -STORM EA. 200 PT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
-
.don laws al' California. Dam
Applicant
GRADING FEF. �-
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Cnmpenmtion provisions of the labor Code. you most
WATER SYSTEMITREATING
SOILS RIE
forthwith comply with such provisions or his permit shall be, deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is tium,tmetion lendingagency far the pebicrmonca.f
NEW RESIDENTIAL PLMB. SQ. PT,
PAID
Dem ce
the work for which this permit is issued (Sec. 3097. Civ. C.)
Landers Name
Lenders Address
_TOTAL'
A
BUILDING F'E �s
1 certify that I have read this application and state that be above information is
correct L agree to comply with all city and county ordinances and state laws miming to
building construction, snit hereby authorize representatives of this city to enter upon the
QTY,
MECHANICAL PERMIT
FEE
SEISMIC FE VV
PERMIT ISSUANCE
above-mentioned properr far in ,ce,tion purposes.
(We) sora to save, indemnify end keep hmtnlaw the City of Caperton against
ELECTRI E
liabilities,judgments, costs and expenses which may in any way meme against said City
in onsasimum Of the granting of this Knout.
ALTHRORADDTOMECH.
PLUMBI F'EE
AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of ApplicaMContmctor Due
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION EE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store orhandle haardous material
as defnad by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cale, Section 25532(x)?
HEATING UNIT (OVER 10100) BTU)
❑Yes IFI NO
PAID
Dan, R M
VENTILATION FAN (SINGLE RFSID)
BOILER - COMP (3HP OR 100.00s) BTU)
Will the applicant or future building occupant use equipment or devices which
rh.arders air cmunininomts as droned by the Ray Area Ail' Quality Management
BOICER -,COMP (OVER 100.000 BTU)
i'mct?
❑Yes ❑No
AIR CONDITIONER
' I have read the harallous materiels rem
yu'veenti under Chapter 695 of the Cali-
ISS C
NEW RESIDENTIAL MECR SQ. FT.
fomia Health & Safety Code, Sections 25505,25533 and 25534. 1 ualea and that if the
buildingdms ntn currently haute rental, the it is my responsibility m notify the accupant
17Iff,
of the emi irements which most he met prim m awcance of a Cemificste of (kcu sucy.
s(7
ISSUED BY:
T A
Ownerorauthodeedagent - Dam
OFFICE
•
KENNETH NELSON
Registered Civil Engineer
940 Saratoga Ave. Suite 218'
San -Jose, California 95129
(448) 247-2898
October 24, 1996
Job No. 956104
Building Inspection bepartment
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014
Subject:.Foundation recommendations for a One Story residence
addition at 21877 Corte Madera Lane, Cupertino, Ca:
Gentlemen:
iAt the request of the General Contractor, the subject property
was inspected by the undersigned on October 24, 1996.
The inspection verified that the soil conditions observed were -as
per my recommendations of October 24,1995. I therefore approve
the foundation excavations and construction.
If there are any questions regarding this subject, please contact
my office.
Very truly yours,
Q�®FESSl��q
H el -
Ke eth Nelson, oz
Registered Civil Engineer #22023 No,22023lot a
M Up. 940-97
KN/kn
cc: Mr. Howard Webber