S 1371-APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAI
dor N
0421Ai 1464vo rll/ ��4 /S W
LICENSED CON'IRAC IOltS DECLARATION
1 hercny affirm that I nm linm.,ce nn,iei, pmvi.ane, of Chap
with Section 70001 of Ilivision 3 of the Business and P nlessim, Cod
in nal farce and erteeL \
LiceContractorClClassDone
`
ARCHITECT'S DECLARATION
\
I und,ty and n,y plan, shall be used as public nsoN, \
ADDRESS'.
it AJrkp/o j A 66,0 d
n� o mu` -Low- o6A.; ee
Consultant Fees Paid by Applicant (Initial) _
11(,,murenming QTY ELECTRIC PERM IT
ondmylicenmia PERMIT ISSUANCE
APPLIANCES —RES I DENTIA 1,
PANELS
UPT0200AMPS -
201-1000AMPS
OWNER-RUILDF,R DECLARATION
1 hereby off nn that 1 am excmpd from the Contmtmr's Lieo\L1�(Inr cite
LU following reason. (Section 703 L5, lousiness and Professions Coca: Any city X my
YWQ ylQ"j which requires a permit to mtvarucn other. 'Improve, depachsh, art repair any o;hXam
J prier to its issuance, alw requires the applicant for such permit m File a signed statei I
ythat he is licensed pumnsnt or the provisions of the Contractor's license Law (Chapter 9,
(commencing with Semion 7088 of )Melon 34 the Raci nesrnnd 11 1c,,am, Code)nN
(bat he is exempt therefrom and the basis for the alleged exenhption. Any violation of
+1 ^ m Section 7031.5 by any applicant for a permit subjece, the applicant no u civil penalty of
Spoat mora than Ilse hundred dollars ($51111).
❑ I, as owner of the property, or any employee., with wages as their sole compensation.
will do the work, and the wartime is nal Intended moflemd for sale (Sec. 701L Business
ycad ProRossini, Code 'the caromont's License Law cines aid at , vn owner of
pmpery who builds nr improves thereov, and who does such work himself or through
hiswn employees, provided that such improvements arc not intended or offered for
sole.If. however, the building er improvement is sold within ono yeamd completion, We
er-builder will have me LwNen of proving that he did not (wild or improve for pnr-
ph a orsale.l.
❑ 1, as owner of the prolmny, vm exclusively cam ratting with Incensed conmucton, to
nmmrct the projeet (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law laws not apply toanmenerofpct,peaty who build, or improves thereon,and QTY.
who comrans for such projects with it cmntramons) Iiec7,wd pursuant in the Contractors
License law.
❑ I am exempt under Sec ,B& P C for this reason
Hate
x nor,)YORKER'S COMPENSATION DECLARATION
'1 hereby offmh ander Penally of price, one 0 the following drelaradorm:
❑ I have and will maintain a CertifcroeofComo:nun self -insure oar Workers Camper.
sailor, as pravided liar by Section 37RO of the Labor Code, fur the permrmmce of the
ark for which this pertdt is issued.
❑ 1 have and will mainmin Workers Compensation Insurance, as required by Section
3700 of the lattice, Cuda for the perfurmmoce cl the work for which this permit is issued.
My Worker'., Compensation Insurance carrier omit Policy number are:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANC12
(This section need mot be emadeted ifthe pomdl is forone bundled Rolla, ($1001
car Imss.J
I certify that in the nrltamance of s per
the work for which phimit is issued, l shall
not employ any penton in any manner so as to become subject cache lPorkers' Compen-
z cation Laws of California. Doe
Z Q Applicant
(7 NOTICE. 10 APPLICANT: If, after making this Certificate of Exemption. you should
a tieco om subject to the Workers Cmnpcnsalian Provisions of the Labor Code, you mush
forthwith comply with such provisions or this permit shall be deemed moo ked.
Uas Q CON S'1'ItUC'I'ION LENDING AGENCYad
0 l hereby affirm that here is a constme;ion lending agency for the perfomsance of
LL. the wad fer which this permit is lssuedSer. 3097, CI, C.)
0 U Izndoes Name
W Lenders Address
I certify that I have read this application and stole that the above if ornution Is
F' Vat] roamer. l agree to comply with all city and comedy onl'manees and slam haws relatingm QTY.
U Z building construction. and hereby amborize repmsentmives of this city to enter upon the
'—I abovo-mmntloned property for inspactian purposes.
(We) agree to save, indemnify and keep hamdces the Coy of Cupecian agaiml
liabilities.judgmefns, costs and expenses which may in any way acerae against said City
in nsen hence of the grand its of dols pc
APPLICAN44JNDHRSTANDS A Wll.l. MITY WITH AL1. NON POINT
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or Puce, building occupant store or handle bmarcumn material
as dcfned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Calc, Section 255320a)P
AYe.v Fl N.
WIII the applicant nr lumre building s,,,soI use ey nipon nt is, desiax which
emit hamNnus air conlaminan s as dcfned by the Bay Arca Air Quality Management
District^
E3 Yes E] No,
1 h' ad be himic s macrial 'remems antler Chapmr fi 95 of the Edi
rami eulth Sufmy C'otlne, Semion 51k5, 2 539 Imd 25534. I understood dam if hhc
bu' res dcumm9�avet Lthnl it' mymshmeibilityborada dwachipant
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'I EMI'. MM ER OR POLE INS'('.
POWER DEVICES
NEW
(EA)
F.A. 200 FT.
PERMIT '
PERMITISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT' (TO 10,1X110 CFM)
AIR HANDLING UNIT' (OVER 111,000 CPM)
[ciAUST HOOD (oto
HEA!ING ONIT (TO 100,100 BTU)
HEATING UNI'( (OVER I00,(X1) FTIO
VENTILATION FAN (SINGLE; RESIII)
BOILER — COMP (3131' OR 100,000 ETU)
BOILER —COMP(OV 17R 100.009 RTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIT SQ. FL
,......... 1371
SANI'IARV NO. APPLICATION SUBMI MAL
3IG C
Z
NIC CONTROL#
BUILDING PERMIT INFO
FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL
❑ KITCHEN REMODEL
❑ADDIT(ON
El PLUMBING RE -PIPE
❑MUI.TI-UNIT
❑STRUCTURAL
MODIFICATION
❑INTERIOR
❑ CHIMNEY RI7PAIR
IMPROVEMENT
❑SWIMMING POOLS
❑HAITI REMODEL/REPAIR
El DEMOLITION
❑ OTHER
COMMERCIAL'
❑ WBLDO/ADDITION ❑DEMOLIT]ON
SANT FOOD SERVICE
MPROVEMENT
❑OTHER
SQ FT. FLOOR AREA $ISQ. I
9R 16 AUS -9
Ur wrcnlllvU
VALUATION
' STORIES 'I'YI'E CONS'IRUI
OCC. GROUP
BUILDING DIVISION I7EES
PLANCHECK FEE,
ENERGY FEE
GRADING HE
SbII`''ppS THE
AID
y owe Rearyn u
Hli? I' SEISMIC EEE -
ELECTRIC HE Ess
PLUMBING F17E
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
('AID Date ireir lof j
TOTAL: I '1N
0 Inspection Query9a Specfic Permit 6/4.8
PERMIT#! 1T:US_ST:_-SITUS"S7REETLot#`INSDESCRIPT,InsTypUATEDESIRE
DateDo'nelnspecto
U_nitsPass/Fail
Cone=
S1371 10275 DE ANZA
-1 -0 -275 -DE
FRAME -R
3/17/98
3/17/98JB
3
P
S13711 ANZA
ELECT -R
3/17/98
3/17/98JB
2
P
1371 10275 DE ANZA
FRAME
3/19/98
3/19/98 CC
1
F
S1371 10275 DE ANZA
ELECT
3/19/96::3/19/98
CC
1
F
S1371 10275 DE ANZA
FRAME
3/23/98
3/23/98 JS
3
P
S1371 10275 DE ANZA
PLBG-R
3/26/98
3/26/98 JS
3
P
S1371 10275 DEANZA
MECH-R
3/26/98
3/26/98 JS
3P
S1371 10275 DEANZA
�FIREDAMPNER(S)
4!9/98
4/9/98 CC
3F
Page 1