20422APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Build Ing Add reel:
PERMIT NO.
n O
10100 Ave. Unit 222 (F1.4)
G
wne422
yyT��oyyr��re
rs a� V one:
Con Tactors amc PrD{1er— Lic Nu
738-4444
CITY OF CUPERTTN0.BUILDING DIVISION
APPLICATION/PERMIT
BUILDING-ELECTRICA4PLUMBINGMECITAMCAL
A A
5/10/90
CATEGORY
CONTROL«
'
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
PERMIT INFO
Address:
f—IBUILDIIIN'7G
`zY 'zY
PERMITISSUANCE 12
LICENSED CONTRACTOR'S DECLARATION
formed
I herebyion 70 t0) of iv Bcen3 oftheerprwlalomof Chapter
pr
ssions9(mmmmc
Ingwith t...11.full form al DiWfect. o(the Buslrassand Professions Code, and my
license is In fun roan and effect.
License Ctsm Lla«
Date Contractor
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
RCB
D �Ar L
,
PANELS
NI.IEEEAMP3
ARCHITECTS DECLARATION
I understand my pkns shall W used u public remmda
OVER I O(q AMPS
SQ. Fr. FLOOR AREA
S/SQ. FT.
SIGNSELECTRICAL
Licensed Pr f.ional
OWNER -BUILDER DECLARATION
I hereby afBrenthat l am exempt from the Contradore License Law for the
(ollowing reason.(gedlon 7mlS, Buainese and Prefeeebns Code: Anydtyor
county which requbes a permit rocensbud, after, improve, demolish, arrepair
SPECIAL CIRCUIT/MLC'
985
74.92
TEMP METFRORI'OLE INST.
anystrudure pdorto its bsuance, alwrequlresthe applicant for such permitto
file a signed statement that M is beamed pursuant to the provisions of the
Contractor's License Law (Chapter 9(cemmencing with Section 7000).( Divi-
don3 ofthe Businessand Prohash uCode) orthat bets exempt therefromand
POWER DEVICES'
SWIMMING POOL ELECTRIC
VALUATION
the basis for the alleged exemption. Any violation of Sedlon 7MIS by any
applicant fora permit subjects the applicant to a civil penalty d not more than
OI11LETSSWITCHF&FIXTURES
$73,796.00
Ben 1, as
dalbmhepr.
1, as owner of the property, or my employees with wages their dale
NEW RESIDENTIAL ELECTR SQXT.
STORIES
TYPE CONSTRUCTION
ea the work is
etmdureh not intended r for
V -p]
.1. (Sec.onper
dale (Sec. 0K 1.4s and fegim Code The License Law
License L
art
does not to rope ty
apply ow f propertyor improves and
who doementsa orktinten odoraugh hicowne.
ssuchtoanoweeiofprough his enemporlmprwvided mrythat uch
OCC.GROUP
RES. UNITS
If, hoes,provieedltding r
Improvements intendneyearfcomraffered .Teale. ILhoweerrWitdcrwfll
TOTAL:
R-3
improverrent tsnld within one yearofcompletlory the owner -W Bderwlll have
have
tf,tIurden of proving that he did not build or Improve for purpose of sale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to censtmd the project (Sec. 70K Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
MN
PERMIT ISSUANCE 1L
The Contractor's License law does not apply to an owner of property who
Wilda or improve thereon, and who contracts for such pV)eda with a
�gRtfa&W.) licensed pursuant to the Contractor'. License Law.
nal am exempt under Sea B k P C for this mason
_
•
ALTER -GRAIN &VENT WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N'
RECEIPT If
Owner Data
WORKMAN COMPENSATION DECWRATION
❑I hereby affirm that 1 have o certificate of convent d spythsure, ora
380,Lab a(Workema'Compensationlnsunnm ora certlfkd copythereof(Sec.
Polis his CJ
Policy
FIXTURES PER TRAP
SCI IDOL TAX Y_ N_
RECEIPT «
GAS EA.SYSTEM-1 INCAOUTLEIS
PARK FEE Y N
RECEIPT «
«
Com any -
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
led copy Is hereby filed the city
seined copy Is tike with the city inspection division.
GREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(This section need not be completed If the permit b for one hundred dollars
Date RC i tic
SEWER -SANITARY -STORM EA. 2E0ET.
WATER HEATER w/VENT/D-FOLK
ENERGY FEE Y N
(IBEBorlesdJ
Icertify that in the performance of the week for which this permit is issued,
WATER SYSTCAT/TREATING
I shall not employ any person In any manner an as to become subjed to the
Workers' Compensation laws of California. Date
PAID
Applicant
NOTICE TO APPLICANT: If, after nuking this CertRkate of Exemption, you
should become subjM n the Worker' Compenurtion provisionsof the Labor
Date Remi tis
NEW RESIDENTIAL PLM B. SQkT.
TOTAL:
Cade, you at forthwith comply with such pmeblonsar this perrrdtshall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I NG '
SEISMIC FEE
5.18
( hereby affirmthat then tat a construction lending agency for the perform
..m.f the work for which this permit Is Issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have madth0 applialionand statethattheabove(nformatlon
Is Cm red. l agree to comply with all city and ceuntyardlnarms and state laws
TOTAL:
ELECTRIC FEE
6-•-6.3
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE 12
FEES PAID:
,
relating to building construction, and hereby autho irs representatives of this
city to enterupon the above-mentioned propery for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against liabilities, judgments, costa and expenses which may In any wayaccrue
against said Cl inn of tin (thlsparmlt
1 b
ALTER OR ADD TO MECH.
-
Date Reeel tic
AIR HANDLING UNIT (TO 10,M CFM)
SUBTOTAL:
AIR HANDLING UNIT(OVQt 10,000CFM)
CONSTRUCTION TAX
Signature of App Contractor I Me
D(}IAUST HOOD (W/DUCT)CONSTRUCTION
TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 10E,OE0 BTU)
Date Rece1 tis
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 1, and the
I le❑alt Yemi Safety Code, Section 25532(a)7
No
HEATING UNIT (OVER IW,00E BTU)
TOTAL:
VEND LATION PAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future Wilding occupant use equipment or devices
which emit hazaedousabeontaminantaas deflved bythe Bay Area Air
Quality Management District?
Yee ❑❑ No
havemad Healthe h of
ardfer mode, Sectionsb5533 and 25511.
the Gltandt that if
A building ant that i
Code,sntly have
undempontandthm not
requir haven tenant that it
'
PAID ^ I®
I ii'sl 1 a 1a44Q
BOILER -COMP (311POR 100,000 BTU)
BOILER -COMP (OVER l00,IXD BN)
NEW RESIDENTIAL MECH. SQ.I•T.
responslbBlty, to notify the occupant of the requirements which must be met
notify the occupant a met
pan.
prior to issuance of a Certificate ofOavry
/s
t9 O f f!BnRtiinn
ISSUED BY: L
Owner or authorized agent Data
TOTAL:
OFFICE COPY