22160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building Project Identification PERMIT NO..
a Building Address: 22160
Owner s ame: 7- \ ne: A A A
CITY OF CUPERTINO-BUILDING DIVISION
ntractore Na :� �Lic. APPLICATION /PERMIT -� 3 —7
BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/ er. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby
af.700O'hat lam Bcen3oftheunder inassaomof Chapter9de,and c APPLIANCES-RESIDENTIAL IOB DESCRIPTION
ingwit ISI fon7000)of Dlvision3ofthe Businessand Pro(essionsCode,and my �
Date
Ej lnmg meand dfect� PANES
License Clasv_� Lk.# s
.Cort
Date t� I n f CHITECTg DECLARATIO �S 281-1000 AMT'S
2 I understand my pkre shag be used as pubbc recards OVER 1000 AMPS 5Q.FT.FLOOR AREA $/SQ.FT.
µ1O
K L SIGNSEL.ECTRICAL A L E D I N
u Licenses Professional '
<<W OWNER-BUILDER DECLARATION p T E R
�' E3 6PECIALCTRCUIT/MISC
I„ ) (hereby affirmthat l am exempt from the Contracmr's License Law for theAML
709 "4 following reason(Sedlon 7031.5,Business and Professions Code:Any city or TEMP M=ORPOLEINST.
F�y� c ntywhichrequiresaper tomnsmMalter, pmve,demagah,orrepalr Q
.: anys<rudure prior to lta Lwrance,alw requimthe appBcant for such perMtm )OWER DEVICES
O a ilk a signed statement that he is licensed pursuant to the provisions of the
q Contradoes License Law ha erg(commencing with Section 700D of Divi-
W 3 ( B ) SWIMMING POOL ELECTRIC
f„ vebasis fo thealleged Professions Any violation V exempt therefrom and ,^ VALUATION
the Wale for the alleged exemption. Anyviolationtolacivi of Section 70315 by any OUILETSSWOCHFSFU(TURES _W L-5)
r O
�« appgcandred permit rs(S5 subjects the applkanttoadvil pevlty ofnd morettun
ce. Gve hundred dolUn($500). -
NEWAESIDENTIALELEC]A ST ES TYPE CONSTRUCTION
❑I,as owner of of property,or my employees with wages r offered
sole �'�'
m(Sec.7 44,will BusBothe work and the iom Code:The
not intended or offend for
sale(Sec. 44,Business and Professions Code:The Contractors License Law
�$$ doesnotsuch toanowner ofthroug hisonemplds orimproves ovidedrron,and OCC.GROUP RES.UNITS
whodo Bauch workhimsei(orthr"ugh hisownemployen,Orovided that such
impmvements are not Intended oroffered forsale.If,however,thebullding or TOTAL: 70
improverrcnt u sold wilhln one yearofcompletion,the owner-bugderwlll have
the rden of proving that he did not bund or Improve for purpose of sak.). QTY. PLUMBING PERMIT FEE -FLOOD TONE APNr
[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor to canatmd the project(Sec.7614,guide....d Professions Code: 2�
The Contracture License Law does net apply to an owner of property who ALTERDRAW&VENT-WATER(EN -
builds or Improves thereon,and who contracts for such p(ojecte -
with a FEE SUMMARY
co,,n��tffactor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
-fJ I am exempt under gee. B &P C for this reason
DRAINS-FLOOR ROOF,AREA,GOND. SANITARY Y_ N_Owner Date E
RFGPT#
WORK MAN COMPENSATION DECLARATIONFEXTURES PER TRAP �.0 SCI100L TAX Y_ N
❑1 hereby affirm that I have a ceemrime of consent to oseff-insurs,theme ora RECEIPT#
certificate of Worken'Compensation lruuranm ora certified copy<hemo((Sec. GAS EA:SYSTEM-I INCAOUTLEIS PARKFEE' Y N
3800,Lab C.)
Polky#_� u S g8-�.�, 15sl S9 t GASEA.SYS E-OVER4(EA)
RECEIPT If
Com any_eP ,l AZ -rr� I!M BUILDING DIVISION FF.ES
oCertifindtfl0d y fileresbyd
mesh GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCKECKFEE
�Cenifed copy is llkd with the dry Impection division
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FT. Date Recei t#
(Thissedlon need not be completed If the permit Morons hundred dollars
($100)0r1ess.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I certify that in the performanm of thework forwhich Nis permit Is Issued,
I shall not employ any person in any manner so as to become abject to the WATER SYSTEM/TRFATfNO
Worlams'Compensation Laws of California.Date PAID
O Z Applicant NEWRESIDENTIAL PLMB. SQ.FT. DatC Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Workers Compensation provisions of the Labor TOTAL:
tr n Cade,you must forthwith comply with such provisions.,this permit shall be BUILDING FEE J.00
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihercbyaffirmthat there lsamm<mdion lendingagency forthe perform TOTAL: ELECTRIC FEE
Z ante ulthe workfar which thin permit b kuued(Sec.3097,Civ.Q .OD
0 O Lender'sName,
PLUMBING FEE _D(7
LL I- Lender.Address QTY. MECHANICAL PERMIT FEE
O W Icertifythalhave readthbapplicatlonaM statethatthe above Information MECHANICAL FEE �-
a is carrecL lagreeto comply withalldtyano.,unry ordinances and state laws Z.
PERMIT ISSUANCE -0� FEES PAID:
7. relating to building construction,and hereF�authomm representatives ofthis
F Z city to enter upon the above-mentioned property for inspection Purposes. ALTERORADDTOMECH. ADD Date RCCCI t#
(We)agree to{"ssa,,v„e,Indemnify an d keep harmless the City of Cupertino P
V agairet gabisn Bties,jd¢mems, dexpenseawhichmaylnanywayacaue AIRRAN)LINGUNLIHO10,000CFM) SUBTOTAL: Vw2.
all ' t vid ty['`XT_"-,n n o e - of this permit -
943-Qi— ALRHANDLING UNIT(OVER I0,OOOCFM) CONSTRUCTION TAX
Sig\tuff of AppB AZAFL Date EXHAUST HOOD M'/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theaPPlicant or futurn buit IMRuvpPaCt ostore or handle harsrdous HEATING UNIT(fO 100,ODO BTU)
-
Date Recei t#
alasdefnedbytheCu no cideChaper9.12andthe
HcAhandSafetyCode Ion75532(.)7
HEATING UNIT(OVER 100,000 BTU) TOTAL: -:)b
❑Yes LIJ No ,-
Willtheapplicantorfumre building occupant use equipment ordevices VENHILATION FAN(SINGLE RESID) ISSUANCE DATE
whichnmltharardousair on taml sae defined by the Bay Area Air FWD
S Quality Marugain District BOILER-CAMP PTB'OR I0(LM BTU)
[?hYes o MAY
ave read the hue ousmaterialsrequimm ntsunder Chapter6.95of BORER-COMP(OVER 100,DDO BTU) tR^{ 1
the California Health&Safety Code,Sections 25565,25533 and 25534.1 ^1 147 H'lW
understand that if the building does not carrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.'
resporeibgitymndify the"ccu anto roquirements which most be met /1j� �[//�1���� raaa
prio suanc o(a erBficat o O ney. C/W'YY�uV
Data (
Own ror aulhorired agent `Date )SgUEDB
TOTAL: . O
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J. R. METZGER
y 1700 SEASCAPE BLVD.
• APTOS, CA 95003
^ ` (408) 662-2466
May 22 , 1991
To: City of Cupertino Building Inspector
Re : 10461 Lansedale Avenue
Cupertino, California
Permit #22160
I personally, Jack R. Metzger, visited job site at
10461 Lansedale Avenue to inspect wire and paper
backing. After cutting inspection holes in sheetrock
and chipping away parts of stucco, I am satisfied this
job complies to meet U .B.C . section 4706 .
I also have photographs which are available upon
request.
A HEW
t+
MAY z
BLDG. INSPECTION DEPARTMEN1
16177 0111 Of CUPERTINQ.
TF OF CA1.�FQ
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