24750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-ELECTRICAL PERMIT NO. l/� /pp�APPLICATION/PERMIT PLUMBING-MECHANICAL. Z T I V7r^
O
BUILDING DIVISION BUILDING PROJK CT IDENTIFICATION V
BUILDING ADDR SSSS - SANITARY NO. APPLICATIONSUBMITTALDATE
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(IC7 r6 UNIT# LOT# �t
OWNS SNAME: P NE: CO fRACT 'SN ME: LIC
Aryr/y� f `!a N/C CONTROL.#
1IV
RCHITECT/ENGust R: ����/ LIC NO: /Y ADDR S:
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
i�T L�9l2 2/2 EL T PLUMB MECH
7 Z L C PERMff ISSUANCEis
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL JOB DESCRIPTION
omz I hereby affirm deal am licensed under provisionsof Chapter9(commencingwith _
WOO Section 9000)of Division 3 ophe Business a uypy`�a��� dmylicurssmin PANELS
y�zw r1rA. It�I�Q�
lfull brilliant ellen. svV�m `
Fzw 'ens Lic.# UP TO 200 AMPS
rn Q L GOnlmnar - 201-1000 AMPS
F'n rn ARCHITECTS DECLARATIONSQ.FT.FLOOR AREA S/SQ.IT.
z Oyu OVER IOOOAMPS ® I
OZ-0 I undmstend my plans shall be used as public records.
Q4W SIGNS ELECTRICAL
Y � Licensed Professional
�C OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /1 f,�
I hereby affirm that 1 am exempt from the Contractor's License Law for the _ �?, r JI �'
p�3 W m fallowing reason.(Section 7031.5,Business end Professions Code:Any city m cnunty TEMP.METER OR POLE INST.
p'trIt< whi,limsmiresa Two[ la construct,after,improve,demolish,orrepin any svuewm I ��/
N of issuance,also a lican[forsuch uofilensi nedsammem POWER DEVICES
prior requires pp pract g TE
M 9
politic is licensed pursuantcoon 7 he provisionsmonf Me Cnmracvess License scum, oder
aye, 9 that he is exempt therefrom
and
Division Sof the Business and Professions Code) SWIMMING POOL ELECTRIC VALUA'IJ'(jj
XyJ,�,n or that he is exempt and the basis for alleged exemption.Any violation o OUTLETS-SWITCHES.
ZpZpZpQ Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of FIXTURES 120
Z❑ [more than five hundred dollars(S5D0f
L`A NEW RESIDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
m m❑ Lhowrk.and epstruct ormyemployestorofth wngesastheiXce.compensation.
H9
and do wons node:The cure lsnm's License
a serofw doesed not apply t an Business
and Professions Code:The Contmcmrs License ids does not apply ro an owner of
properywyces,pdeor ed arves that suchimonandwho we notihwmkhimsenedthrough hisown - OCC.GROUP RES.UNITS
employees,p building
a,i provement iold within
sinne iearrofdmoffered foracIleo e.If,
however,the building m improvement is sold within one year ofwprove oq thepme,of
builder will have the burden ofprnving that he did not build or improve for purpose of '
,.afPLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,ax ownerofthe progeny,am exclusively contracting with licensedconoacmre to QTY.
continue,the project(Sec.7044,Business and Rofessinns Cade)The Contractor's
License Lowdoes not applym an ownerofproperty whobulldsorimproves thereon,and PERMIT ISSUANCE
tic
who contracts for such projects with acomractm(s)licensed pursuant to the Contracmrs
License Law. pLTEft-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner - Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ 1 hereby affirm that 1 have a certificate of consent to sell inside.ora carlficate of TFIXTURES-PER TRAP ass— RECEIPT If
Workers'Componsadon (Sec.380e,Insurance or a certified copy thereof Leb CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company- GAS-EA.SYSTEM-OVER 4 RA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed whit the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is redone hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I certify that in the ofthe work forwhicbmis Permit is issued,l shall WATER HEATER W/VENTIELECTR
not employ an .Manner sa as tm become subject to the Workers' PAID
pensation "" 6inia. Date WATER SYSTEM/IREATING Date ceipt#
O APPlicant
NOTICE TO PLICANT.If raking this Certifce[e of P.xemption,you should NEWRESIDENTIALPLMB. SQ.FT. six
TOTAL:
F h becomes cuethe Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this Permit shut[be deemed revoked. BULMG
L2a Q CONSTRUCTION LENDING AGENCY fElsilPFEE 4
Z I hereby affirm that there is a construction lending agency for the performance of O ELECTRIC FEE
O the work for which This permit Is Issued(Sm 309],Civ.CJ
Lenders Name PLUMBING E
F Lenders Address' - - QTY. MECHANICAL PERMIT FEE 14
V 1 certify that I have read this application and state that the above information is �i [PAID
CHAN AL FEE
cornet.Iagrce to comply with ell city end county ordinances and emtelawarelating to PERMIT ISSUANCE
building construction,and hereby authorize representatives of this cirymenter upon[he NST UCI'ION TAX
L.) Zabove.mentioned property far inspection purposes. ALTERORADDTOMECH.(We)a� y demnify and keep hmnlasa theCity of Cupeino against
liabilitiesp]6dgoe diIce wdexpenses which may in any way acerueagainst said City AIR HANDLING UNIT(TO 10800 CFM)
fp noting of this permit.in e n � AIR HANDLING UNIT(OVER 10,1X10 CPM)
/11/413
Si re of uincinumenr Date EXHAUST HOOD(W/DULT) � �
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 11)(1,000BTU) Date Receipt#
Will the applicant or future building occupant store or handle haurdeos material HEATING UNIT(OVER Iflo"BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section25532c)?11 Yes C1 No VENTILATION FAN(SINGLE REBID)
P A11SIONCE DATE
r_�l Willthenpp goccupan q Amen IicnntorfuwrebuiWin msec ui tordeviceswhich emit BOILER-COMP CHP OR 100,000 BTU)
not elr contaminants as deft by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
FEB y 8 1993
El Visa 0 N NEW RESIDENTIAL SUCH, SQ.FT.
I have read the hamrdous materials raparemems under Chapter 6.95 of the CITY r- LUr
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that V CI'I I ullu
if the building does not currently have a tcnamt,that it is my responsibility to notify the
occupant or the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or amhmised agent Data / ISSUEDBY:
OFFICE