26686 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECI RICA L I PERMI'rNO.
APPLICATION/PERMIT PLUMBING-MECIANICAL [v Q Q
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION U v o
BUILDING ADDRESS: (� J SANITARY NO APPLICATION SUBMITTAL DATE:
107-1 1 /T 1Ver br�h L�6-ItE DNI,'N LD,'N �
OWNERS NAAffy _r PHONE CONTRgC�`SfAM� ay� 0 LIC NO LL{
•SS���� JNJy�C/ /{�1J/{gc 1V x �_/ 4/}Dz CO/IHII NIC CONTROL 0
AIICIII'R:C,'/I INIiI:H I,IC NO' A1f0 T �vlJi�(CI C` �� 0
CONTACT: PHONE f�//�) BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE _
I RLDG IA,GCT PLUMB MliCll
PERMIT ISSUANCE _ — �Z� � I El
LICENSEDCONTRACTOR'SDECLARATIOa APPLIANCES-RESIDENTIAL. \/ JOB DESCRIPTION
Mai I herebyeffrm that lam l evesedunder,nskime.fChup¢r9lcnmmenetngwroth
1x1010F.. Section 70 oI Division 3mf the Beninese it Pedcrruiraw Code,and my license is ten PANELS // /`me an QO, Laclede Cluseffay...,i I.mM �.l' �� UPT0200AMPS I 1/�,�f'('//
oor o, Date /U/'f[/�G!/erg Cnntmcon ii ay o✓V� 281-ANNE AMPS l' iii
Z~OyZ ARCHI'I EC'I"S DECLARATION SQ.FT.ILOOk AREA E/SQ.FT.
Iyn}cyt dryT�lans�5h beu public ends
OVER INS)AMP5
FNW _//'/'y,w/�7l-/ en SIGNS ELECTRICAL. ,.
Q ,� Licensed lknfe.Csionvl OWNER-BUILDERDI;CIARA,'ION SPECIAL CIRCUDUMISC..
56Oy 1 hereby afftrn that I am exempt from the Contractors License Lew for be
Yl�+sr-ya fallow.ngrcamn.lSecunn]831.5.BUSmeas and Pbfit.ans Code:Any city orcoutny TEMP.MITER OR POLE INST.
F B"10 I which regmres a perms termmmoct,uber,improve,demolish,or repair any suurnme
!!;y� prior to ms usumice,also requires the applicant tat such perntil to file a signed scerient POWER DEVICES
a a C,C that he is licensed pursuit to the pow... ru of the Contmnors License Low(Chapter
d OLL'19(commencing with Section 7")of Division 3 of the Business and Profovomo Cade) SWIMMING POOL ELECTRIC '1 / VALUATION
or that he is excinpnhertlrom and the basis for alleged exemption Any violation of ,�/ /
�Za eil�`nreshunEvehund hundred sr19 'ns ubjrmsiheapplicamtoacivilpnivltynf (OUTLETS-SWITCHES-FIXTURES �jO /Vl
W � ❑ Lmnwnernftheprnp ry,ormyemploy swithwagnsstbeirsdecompcmouoe, l INEWRESIDENTIALELECfR _SQ.FT STORIES IYPE CONS,RUCTION
a3— will do the work,and the structure is not ntended or offered forsale(Sec.7000,Business
unit Professums Code:'l he Comnutnr's Lcense Law doer not apply to un owner of
pmpcny whoboildsonmpmvesthereon,andwlmdoes such work IJmselfonarmugh hia
employees,provNed Nat such improvementsare not mtendedmuffertd forsele.IL I OCC.GROUP RES UNITS
however,the huddmg nnmpmvement is sold within one years(completion,theowner- 'f0'1 AL
bodder will have the burden of proving that he did not build or improve for purpose n,
sale.).
❑ I,as owner ofthe limited ,am exclusively communing with licensed contractors to QTY. PLUMBING PERMIT FEE I FLOOD LONE APN
hnswn the protect(Sec.7014,Business.5 Profesaaom Code)The Contractor' n � R
recnse Lnwdncs rim apply man owner ofpropcny who build nnmproves thereon,xn I'pR�1,pISSQ'AN81i r fl 114N _
whnconvace fur suchpmjatswi0ianmuacmr(s)hcensedpursuun0othc Continnnr' ''s�^ff pjTER-DRAIN&I�.VT-
later,Law. a { I WA'fGR TEA) I FEE SUMMARY.1 L❑ I am exempt under Sec B&P C for this rtnsn ` PACK(LOW PROlLC1�D IC I SANITARY OYES DL FEES N
Owner ,AT DRAINS-PLOOR,j�F/Ay�A(sfol I SCHOOL TAX Y CCt�g N
WORKMAN COMPENSATION Dn to IfAT10N E 11XT(IRES-PER TRAP,
• ❑elherehy off ilia l have vicemfcasc of ronsenno self-insure.oracenificaen R[CCtPr'p
Workers Conipensanom Insurance or a centfied copy thereof(Sec.3Sf10,1,abC)whicti IPARK FEE Y N
rsall en`RowJa thigpermn. (GAS-EA.SYS'IEMd INC.40U'TLETS t RECH,PTn
Policy# Cu C/z'r%�F/f dlvH4/ BUILDING DIVISION FEES
Compare s / - I (GAS-EA SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenitieJ Cmpyn hereby furnished.
Cl CenJieJ aipy is]tied wnh the city mspeaion division GREASEINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
fThlsscctianneedn Ibe completedifthe permit is hnone hundred dollars lSlulq (SEWER-SANITARY-STORM EA 200111' ENERGY FEE
or hiss) _
I cedifymat inmbe performance of the work fire which ill paean is issued,,shall I WATER,LPATEII W/VF.NT/ELIiCTR
not employ any person in any manner so its to hecome mbtect m the Wo aC ! PAID
Compensation Luwsof CuMamm. Dale WATER SYSTEM/I'REATING Date Res.cipiI
Z Applicant
Z0 ZH0 NOTICE TO APPLICANT If,after miming this Certificate of Exemption,youshmWd NEWRESIDENTIM.PI.MB. SQ TT I TOTAL:(
F� q hemmovitheamthe Workers Compensator provisions mf the LeWrCode,you must --
104 forthwith enmply with such provisions or this point shall be deemed revoked, BUILDINGFEF.
V
z CONSTRUCTION LENDING AGENCY SEISMIC FF.P. - -
�j' (herebyhich Ilh:nthere is issued I Sce.3 lending agency for the Performance or 'TOTAL. ELECTRIC FF.R
U O tM1Cwork No which this lmrmit is issued lgec.d097.Cis.CJ
lenders Nor re PLUMBING FEE,
O U lender's Address IQTY. MECHANICAL I'IiRAf1T' FEB
U I certify that I have read this application and state that the above information is MECHANICAL FEE
r?^
W ...... ]agree mi enmply with all coy unit rnunly nNinunttn unit scitc lows rclming to PERMI'1'ISSUANCI3
(~ lai,, huddmgronstiucoon,and hereby authnnte reprcsentauves of tbiscirymoemer upomhe (CONSTRUCTION TAX
U Z above-mentio m
ned property for sPeeuon proposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
-IiubJiOcsqudgments,cnstsundexpcnscs shimho,ey litany way amemeagainst said City A IR II ANGLING ON IT(TO I e,oco ChM)
in consequence of the rvI gofthsKor m.
Wr / am�� EXHAUST HIOOD(W/DUCI'IR 10,000 CPMI PAID
Siyiiaturc nl Applic:nd/Cn aerator
HAlARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt R
i Wdl the applicam or future bmlJmg acupam store or handle hamNous material
us dclined hythe Cupertino Mams,,adCale,Chapter 9.12,and the Her,and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25532(a)': VENTILATION PAN(SINGLE RISID) - ���_
❑Yes ❑No
BOILER-COMP(IHP OR 100,000 BTU) I ISSUANCE�ATe
Will tire orlumre hnilAingrccupant useeyuipmentordeviccs whichemit P. 'o
hazardous air conmmitmms as defined by the Bay Area Air Quality Munagemcut BOILER-COMP(OVER 100,000 BTU) I C 1 O
• Drsmdcma d 1994
❑Yes ❑No NEW RESIDFMIAh MECH. SQ FT.
1 have rctaf fl a hmmdous materials rcgmremclts under Chapter 695 of the I Vr VVre�t
Califomma Health&Safety Code,Sections 25505,25533 and 25534, 1 understand that
if'he building does not currently have a tenant,that it is my responsibility to notify me
ecupanm of the reyuirancnis w prior to irwan<e'if.Cenifcmeof ..
(1ccuPency� e
)Z Ci' 1'
Owner nr amhonzM egem /J Dete , ' TOTAL: IISSUED BY.
OFFICE