19643APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
PERMITNO.
11.1blo g Add...:
A052;%-)19643
nn: Phone:
L,ar oltw—
Contr ct shame: �— Lie. No:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / P- RMIT
A -
BUILDING-ELECTRICAL-PLUMBIN DCHAMCAL
CATEGORY I
CONTR0es d
j5 O
Lie Nix:
QTy ELE IC PERVW E
BUILDING PERMIT INFO'
�AArrehiited//E,ngineer.
� v�6 l
Address: / 0e
gr'COr
PERMTISSUANCE
N"'YYYTRACEOR'g DECLARATION
LICF.NNSSE D1
I herebyaftirm that l am licensed under provisions of Chapter9(commenc-
effeon3 oflhe Buelamand Pro(eselonsCode,and my
ingwith l ionforceend AfeR.
licce.h Semon force and
APPLIANCES DE * L
- JOB DESCRIPTION
eGy-DII^UV4l,•
PA {,,
License Cion LICA
Date Contractor
ARCHITECTS DECLARATION
e a my p)e�,phpe ed s crtmrde�a'y�a1
OVER I'B
SQ. FT. FLOG AREA S/SQ. FT.
LI sed Pmfeaseal t [* l ! I (J l
51G L 7RICA
FV
SPEC
LCIRCUIT/MI
OWNEReBUILDER DECLARATION
xempt froContractors License Law fort he
Iwing ason.(that lam31.5,Business
�a
Zai �Ir�
TEMP METER ORPOLEI T.
followingremoryiSess pe twBuil sand Professions
ossa
emle hnycityor
countywhlch requlme pemdt tocoatmct, ilter, Improve, demo Wh, orrepilr
-
anystmmmprlortoltsbsuaance,abomquimstheappllcantforauchpem tto
file a signed statement that he b licensed pursuant to the pruvlslons of the
Contrader's License Law (Chapter9(mmmencing with Section 7000) of Dlvl-
sion3 olthe Buslnessand ProfeasiomCode) orthat he b exempt therefromand
the basis for the alleged exemption. My violation of Section 70315 by any
appllnnt fora permit subjects the applicant to a civil penalty of net more thanOr
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHES U(TURES
VALUATION
4j5
NEW RESIDENTIAL ELECTR SQXT.
five hundred 0.1 of
❑I,asownera(theproperty,crmy employees with wages
the property,
STORIES
TYPE CO 57RUCTION
or offered
coopeneatlon, Bu.iMtte work, andthe ssiors Cade:
sae (Set 7064, Code:The Contractors Leaser Law
df The C intended or off Law
to an ownerproperty
does not apply to an owner of property who builds or Improves thereory and
who himself Neowne. that such
OCC. CROIIIP
R . UNITS
ovdoes msuch
nts amwork
intended or If,ho ever, the building
improvementsarcnot Intended carocd flesh .ILhowever,theerwill have
Improvement U sold within oayearofcompletlory the owner -builder will have
TOTAL:
thUmrden of proving that he did net build or improve for purpose of sae.).
LJ L as owner of the property, am exclusively enntractleg with licensed
contractors to construct the project (Sm 704q Business and Prof edom Code:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOODZONE
APN
The Contractors License Law don net apply to an owner of property who
builds or improves thereon, and who contracts for such pkejects with a
mp(pctor(s) Bernard pursuant to the Contranofs License Law.
L -..I I am exempt under Sec. B & P C for this mason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE IT
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES, PER TRAP
SANITARY Y N
RECEIPTX
Owner Date -
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, ora
cenifimte of WorkeWCompemation Lmuranm ora certified ropy thereot(Sec.
3800,Iab C.)
SCHOOLTAX Y_ N_
RECEIPTNN
t' G B�'BTIEM71,!N�A OM'I SMI
PARK FIX Y_ N_
Policy It
RECEIPEA
f —
G rks ErPM-OVER4fEA) q ^„'
Com
BUILDING DI VISION Fit ES
�Cey
ati(led mpy b hereby to
�ienllled mpy b (lied withh the city
he dty Inspection division.
T CERTIFICATE OPIXEMPTIONFROM WORKERS'
G ,E/INDUST6L_W0S i
PLANCHECK FEE
/
PAID�(y 5y/34
��r�1�
GIF \SE RAP
COMPENSATION INSURANCE
(Thleaectien need not be completed If the permit e(or one hundred doll..
($1I andl th m work an as to b the permit a booed,
I certify Mat oIn they person
once any
I shall not employ any peaws In any manner eo m to become subject to the
Wplican Compen.aten laws o(Gllfome. Date
Date Recei til
SEWER FA X10FT �'�'""
WATER HEATER W/VENT/ELEC1R
ENERGY FEE Y_ N_
rAlo_
60,00
WATER SYSTEM/TREATING
Applicant
NOTICEco esubjettothe after makingfhbs.tion Certificate ls Exemption, you
Code, become .forth to the Workers' Compensation orchis permits Labor
Code, you most forthwith comply with each provblom orthb permit shall be
deemed revoked.
Date Rewi til
NEW RESIDENTIAL PLMB. SQYr.
TOTAL:
B I
2.00
SEISMIC FEE
i -
1-75-
CONSTRUCTION LENDING AGENCY
1 hereby Affirm that them is a construction lending agency
1herebyAffirmthattherebaconstructionlendingagency for the perform
an. of the work for which this perect Is Issued (Sec. 3097, Cls. C.)
TOTAL:IrE
ELECTRIC FEE
-
QTY. MECHANICAL PERMIT
PLUMBING FEE
Lender's Name
Lender. Adamaa
l cenitythat l have read this application and atatetiow theabovelnfomutloe
Iscomect. Iagreetocumplywithallcityand rnuntyoneatersand statelaws
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building mmmectlon, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Wpection Purposes,
(We) agree to save, Indemnity an d keep harmless the City of Cupertino
ago UutlbblliteA, jadgmo m,coeteand expense which xray In anywayacmm
cot sold Ity In mos en f the granting of this permit.
_ail
}fes A0
at—ft.
ALTERORADDTOMECH.
Date Reoeiptt!
AIR HANDLING UNIT Q010,1100 CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVIR 10,000CFM)
CONSTRUCTION TAX
—
si P t ontranor Date
HA RDOUSMATERIA DISCLOSURE
ExHAUs r HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(TO 100,000BTO)
Willth pplicant or boom building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12 and the
Date ReCel t#
HEATING UNIT (OVER IW,000 BTU)
TOTAL:
TQ.
Health and Safety Code Section 25531(a)1
❑ Yes No
Will the applicant r tore building occupant use equipment ordevices
VENTILATION FAN (SINGLE RFSID)
ISSUAR
which emlt haaardous air contaminants as defined by the Bay Area Air
BOILER -COMP OHP OR 100,01M BTU)
Qua lity Management DiAttrctl
4 Yes IyI No
R
MAR 1990
BOILER-COMP(OVIR 100,000 B1U)
have read theft ous Materiae rn
mqulmeent uoder Cha pter 6.95 of
the California Health &Safety Code, Sections 25505,25533 and 15534. 1
,
NEW RESIDENTIAL MECH. SQ.Fr.
understand that if the building does not currently have a tenant, that it is my
r spwxsibllity to notify the occupant of the requirements which =at be met
Luua cola rtifleateof0ttupancy.
�Date
er or authorized agent
ISSUED BY.
TOTAL;
OFFICE COPY