20420APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Protect Identification
Hullding Address:
PERMIT NO.
20420
nems ame:v,Q ho e: -
A A
ro erties
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
5/10/90 -
Contra°ora Name: Lie. N.
738-4444
BUILDLNGELECTRICAI PLUMBINGMECI{AMCAL
CATEGORY
CONTROL
Arthltnt/Englnmr. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address
❑X M EN EA
I'ETthRTISSUANCE 12
• LICENSED CONTR
I herebyaffirenfluunder rDECLARATION
DoxtsIson emsed 3oftheerpessandof Cendoes9(e,and
InenseI in fullforce ord vfect. afthe Buelneseand Pro(essionsCode, snot my
license Is Ins rorce,ne deed.
API'LIANCESRESIDENTIAL
JOB DESCRIPTION
RCB
rnNefs
License Clam LIc#
Dale Contracto
UP TO 2DO ANTSu
W
2014000AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as public records.
OVER 1000 AMPS
SQ. Fr. FLOOR AREA
$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
SPECIALCIRCNT/MISC
OWNER -BUILDER DECLARATION
I hereby afflrenthat I am m exempt frothe Contractor. License Law forth¢
985
74.92
TEMP. MERE{ OR POLE INSr.
following .... (SecHon 7031S, Business and Professions Code: Anydtyor
countywhich requires a permit toco.teact, alter, Improve, demolish, mrrepair
any.tmmmpriortuitsL ance,ab mqulmaheappBantfweuchper tto
file a signed statement that he is licensed pursuant to the provisions of the
FEWER DEVICES
SWIMMING POOL ELECTRIC
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi=
Mona of the Business and Professions Code) orthat he is exempt therefromand
VALUATION
the basic for the alleged exemption. Any violation of Section 70315 by any
applicant lots permit subjects the applicant to a civil penalty of not more than
OUTLETSSWITCHESFD(TURES
$73,796.00
five hundred delta.($500).
❑ 1, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTA EQ,FI'.
S[DIUES
TYPE CONSTRUCTION
compensation, will dothe wwk. and Ne structure Is not Intended or offered for
V—N
sale ISer. 7041, B.Mecou and Professions Code: The Cont.dors License Taw
does not apply to an owner of property who builds or Improves thereon,and
who does such work Mmselforthrough his own employers, provided that such
OCC.GROUP
RES. AMTS
improverecnb are not intended oroffered for sale. I(howevegthebulldingw
improvement i3wld withinoneyearofcompletlon.theowner-buRderwlllhave
TOTAL
R-3
/
tfpjprrdan of proving that he did not baud or improve for purpose ofsale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to conamad the project (Sec. 7014. Business and Profesalons Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE 12
The Contractor's License Taw dove not apply to an owner of property who
Wilds or improves thereon, and who mntrads for such plojects with a
cgp(peen emr(s) licensed pursuant to the Contractors License Law.
L� 3 am exempt under SB & P C for this reason
ALTER -DRAIN & VENT -WATER MA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y N
RECEIPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, or a
mrtifkMa of W.,karB Compensation Insurance ora cedRled copy thereof (Sec.
38W'Eab Cd
Policy
FIKTIIRFS PER TRAP
SCHOOL TAX Y_ N_
RFGI]I'I' N
GAS EA.SYSTEM-1 ING40[TILEfS
PARK FEE Y_ N_
RECEIPT #
#
Comm any -
GAS FA. SY5rEM-OVER4GEA)
BUILDING DIVISION FEES
Lfled copy b herebyfamished.thehed.
edifred copy Is filed with is city Impntlon division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
GREASE TRAP
CERTIFICATE OF O(EM PfION FROM WORK ERS'
PAID
COMPENSATION INSURANCE
nt
(Thisslon need seabecompleted lithe permit isforone hundred dollars
(E100)or lewlues.) d
IcertNthe pedomxnce of the wwk (orwhlch this permltlawed,
SEWER-SAM.I.ARY-610RM EA IOOFI.
Date Recei t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
WATQ{ SYSTEM/TRFAlING
I shall not employ any person In any manner so as to become subject to the
Workeri Compensation laws ofCalifornia. Dam
PAID
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Exemption, you
should bemrne subject to the Workers' Compensation provisions of the Labor
NEW RESIDENTIAL Pima. SQ.ET.
Date Recei t#
TOTAL:
B
52 2 , 50
Code, you most forthwith comply with such provhiom orthb permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirmthat there Is a construction lending agency for the perform
ec
ance of the work for which this permit Is Issued (S 3097, Civ. Cd
Lender's Name
Lender. Address
I certifythatl have read thi.applicatlonand rtatethat the above Information
element.I agree to conplywlth all cityand county ordinances and state laws
TOTAL:
ELECTRIC FEE
36.61
PLUMBING FEE6..6$_
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE 12
FEES PAID:
,
relating to building coeutroctlon, and hereby authorize representatives of thls
city to enter upon the abovcmentloned property for inspection purposes.
(We) agree to save, Indemnity an d keep harmless the City of Cupertino
against llabillBes, ju dgmenta,ces. and expenses which may in any way accrue
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT CTO 10,000 CFM)
SUBTOTAL:
against saidC con nre of lege Ng hla permit.
%nali �S�
Sign rco(Appllant/Contracmr D
AIR HANDWNG UNIT (OVER IO,OW CFM)
CONSTRUCTION TAX
EXHAUSTHOOD(W/DUC'D
CONSTRUCTION TAX PAID:
HA7ARDOUS MATERIAL ISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Date Recel t#
Will the appHeant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Ilealthand Safety Code Section 255326)7
Yea No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:13
y
/.
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant w tum building occupant use equipment ord"vices
which emit hararclous air contamimai nts as defined by the Bay Area Air
Quality Management District?
Yes No
have read the baza ous materials requiremens under Chapler8.95 of
the California l{e.Ith&Safety Code, Scotto. 25505,25S33and 25534. 1
understand that ifthe building does not currently have a tenant, that it is my
RAW
F
1• elf 4i 1990
BOILER -COMP DHPOR I0UK0 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the Deco pant of the requimments which most be mel
poorto issuance of a CertiRateof Occupancy.
�Ity 0f rI1611rtIBn
ISSUED BY: 8 (% (•(
Owner or authorized agent Data
TOTAL: I
OFFICE COPY