24 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY k
BUILDING- ELECTRICAL PERMITNO.
CITY OF CUPESION PLUMBING-MECHANICAL 1
BUILDING DIVISION APPLICATION/PERMIT 2 4 \,
B1AL0P1G PRO7KCTtDBNTIFTCATION,1"u1,1,w-jW�,'�e,
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMRT.
2 G UNIT» LOT# 3
N PHONE: / CONTRACTOR'S NAME: LIC NO: �/
CONTROL#AR LCNO: REggZ • ^ rf�/ 2,CONTACT: PHONE: ,#v.' }c,:±' a.»r .=rvw.-e+a. 4y(a 'R"'' arxMu .,',;TT
„ys+'] '.ori'BUILD PERMTT INFG:,s.'45uiP,r �`:
ELE
�rrlcK� qy6—ogr Q , RI�PBR�P,s , _
”' "`r' "- xzn.2+' UG PLUMB PERMIT ISSUANCE
LICENSED CONTRACTORMCH
'S DECLARATION APPLIANCES-RESIDENTIAL /� OB DESCRII'1'ION
LD
Ocez Ihembyafil, that lam licensed underpmvisionsof Cheprer9(commencing with �
FOSection]000)of17 ision3of Ne Businmsmd&ofeuions CWd,mdmylicenreisin PANELS
��� ball fame,nderrat.
FZW Lice.Chis Lic.p UP TO 200 AMPS wa
at,. Data Comvectm 201.1000AMPS
'Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
'C"_"O 1 understand mY plans shell4 card as Public accord.. OVER IOW AMPSDz
_'Ertl SIGNS ELECTRICAL ``llama 8 I V
YKt�VLiccmcd Porfeurmil
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC. 1/t, 4
t O aU I hereby affimt that I em exempt from the Convectors License Law far the "WILLS
{J
���m following aasnn(Seetian]031.5,Bmi•..,and Pmfeuione Code:Any city or aunry TEMP.METER OR POLE INST.
y; which requires a Permit to mm Tact,alter,Lmpmve,demoli.h,or repair any smtatoe
plot mitt,numm'e.al.minutes be applicant for Inch permitmfleesigned aamment POWER DEVICES
O that he is licensed pursmns in the Provisions of the Catvecrnfa License Law(Chapter
_aoLL 9fcommencing with Section]000)of Division3ofNe Businasand Pm(ea.i.m Code) SWIMMING POOL ELECTRIC VALUATION
❑•a or Nm he 31.5 by any
a hermits bectseged Mli I .A ivii,eavon of /� � �te A�1r
(..Z}
Section]031.5 by any applicant forepemtit subjects tM appall [m ivil penalty of UTLEfS-SWITCHES-FlXTIIRES (�M V�
O not more then five hundred dollars(550(y.
C NEW RESIDENTIAL ELECR _SQ.PT❑ Lasmvmeraftheprorte",rmyem to ma, tawrarlec peati.n,
STORIES TYPE CONSTRUCTION
y3— wind.thework,andmeatmcturei...lintandedoroR mule Mec.] .Buaineas
and Profmima Code:The Connector's License V casnotapplyn, owner of
pmperywhobuildsorimprovesthereon,.dwh. suchwarkhmanifor ughhis
ownemplayar,pmvided Natsuchimpmveme arenotinandedaofemA(a sale lL OCC.GROUP RES.UNITS {{
however.Nebuilding=nnpmvementisso ithjnon yearo(o.mpletion,th owner- .P
builderwillhavetheburdrnafpmvin the did not of mimpmv�e f9�p nor
agile). /�' 'z1W -r -, +meuseec.eers aaasc#tray
❑ Lmowarafthprm ,ameaclusively n If IN It. 9P m �S'•"1" PI:UMBING PERMIT EBB ' FLOOD ZONE APN
common the pro' 7(44,Business and ion n ors -• ,_a+sv:;,Y& .
Iianaisw
does n apply toa: wrier. he of impmvea d PERMIT ISSUANCE
whocanLaw.Fasu Peau moi a On
vacmrs ALTER-DRAM&VENT-WATERMA)
License law. '94
eEes'uiatn2v''
❑ lam eaanpt un Stt. ,B Cfa Nis
Owner reawn BACK FLOW PROTECT.DEVICE
SANITARY Y N_ ST,
' te DRAINS-FLOOR ROOF,AREA,COND. RECEIPTM 'tl
WO COMPENSATIOND TION SCHOOL TAX Y N_
❑ 1verebyt utas tat veaarti iteseafc toalf-insuae.aeartifiure of ppR•TRAP RECEIPT# I
Warkeri Contpvt.Nonl aracartifetl
y Nercof(SttJSW,Lab CJ which PARK FEE Y
covers allemploynes. 'a permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy M BUILDING SION FFFS $ -
ContPmty GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK t T
❑ CMlIhdcopyia Iombyfutmshed.
❑ Ccafifisd copy it,filed with NC city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING i
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP gQ IT A ��
COMPENSATION INSURANCE V
(�hisx cn need not be completed ifthe Nornitis Intone hundred dollars($10(f) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE -�
or hens.)
I certify Net in theperfomana ofthe work for which Nispcnnit is lulled,ishan WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to became subject to Ne Workers' PAID
Z Compensation Lawaaf Califomla. Deer WATER symmiTRF,ATING Date <ipt# ._
Applicant
7 2 NOTICETOAPPLICANT:lf.efrermaking Nis Cervfiuteof Eamption,youahould NEWRFSIDENTIALP AHL SQ.FT. OTAL:
C4 become subject to the Worker's Compensation provisions of the Labor Cade,you must
Z � forthwith comply with such provisions or this Permit shall Ise daemon revoked. BUILDING FE
Z. Q CONSTRUCTION LENDING AGENCY SEISMIC
❑ 2 Ihereby affirm that Nae is a construction lending agency for the parfmmence of PH L
O the work for which this Permit is issued(Sec.3097,Civ.C.) 0--' FLECTRI FEE
Lenders Name a' '+day„-ly+na+^sy,+zsas x «c. q. s t.T�
Under Addres. Q79 y MBCHAN[CAL PHRMIT PEE PLUMB
W1 certih Nat I have recd Nis epPlicati.n end state Nat Ne above Infomtat ` 't�4N HAN C -
rat.lagrecmcomply with all city end wumy ordinances Intl state laws mininF to PERMIT ISSUANCE A I
4'y building construction,and hereby authorize representatives reeenuves of this cityuponmenter
Ne
Z above-mentioned property for inspection and keep.ae.. ALTER OR ADD TO MEC', CON TRUCDO TAX
(We)agree nt save,indemnify end which
may ina the City en Cupertino against
liabilities,judgmentsecosaand g ea penseswhich may in any way e<crueagvnst said City AIR HANDLING UNIT(TO 10,0110 CFM)
in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVER 10.00(1 CPM)
Signature of ApphicanUConuaam Dan EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,OW BTU) Date R #
Will the applicant or future building occupant store or handle hmardous material
as HEATING UNIT(OVER IW,t1W BTU)
defined by the Cupertino Municipal Cade,Chapter 9.12.and Ne Health and Safety
Code,Smi El^5532(e)"Yes 11 No
❑ VENTILATION FAN(SINGLE RESID)
Will Neapplicent orfmurcbuilding occupant useequiPtmntordevices whichemit BOR.F-R-COMP(3HP OR IW,000 BTU)
ISSUANCLIDA
hazudous air contaminants so defined by Ne Bey Ares Air Quality Management BOILER-COMP(OVER IW"Irru) JUN 29 199
J ' ❑Yes '❑No NEW RESIDENTIAL MEC'. SQ.FT.
1 have road the hazutdous materiels requirements under Chapter 6.95 of the krl( F Lar U(JramI
Glifomia Health&Safety Cade,Saturn,25505.25533 and 25534.1 undersand Nat
if the building does not currently have a Tenant.Nat it is my mt,ponsibiliry mnotify the
occupant of the requirements which must be met prior to issuance of a Ce=rlicme of
Occupancy.
Owner m authorized agent Date ISSUED BY:
iSCCI(`C t