26792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO -
BUIL IN.-F.LF.CI'III AL PERMITNO.
APPLICATION/PERMIT PLUM RojEcrEDENTICAL 26792 C 7 9 n
BUILDING DIVISION BUILDING PNOJF.CT IDENTIFICATION L�7 .7 L
BUILDING ADDRESS
SANITARY NO. APPLICATIONSUBMHTALDATE
Io v �-Ajf ✓J
UNIT# LOTH
OWNER$NAMF_' H'"ONE: C NTRACPO ' NAME: LIC NO:
r O NIC OLvoN
I! IECr/IvUINEE� LIC N . !^ DDRE55: ❑ IoNTACf: V PHONE: a! BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
Drt�t�i i ,a ELEC PLU B MECH
PERMIT ISSUANCE �ail/fF
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 100 DESCRIPTION
nyZ Iherehy aff romill l are licensed underprovisionsof Chepher9(commencingwith
sF5i 00 Section]:)e f Division 3 of the Business end Profusions Code,and my license is in PANELS —
y�z+ full form and effect.
F6 Limnse Cl., Lic.X UPT02WAMM
ttno Date Contractor 201-I"AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
ZFIy� ARCIIITECTS DECLARATION OVER IBM AMPS
OZ—a 1ondcnlond my plans shall be usedas publicrecords.
Limned ProfessionalaY ty SIGNS ELECTRICAL �OG1k (,
Y ay
Cq� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ,
OyF 1 hereby affirm thx 1 am exempt from the Contractors License Law for the cLt0
3LLm follmingremost. Section]031.5,BusinswoundProfemion.CodeAayciryorcoumty TEMP.METER OR POLEINST. lo9q.
; which requires a permit to construct,after,improve,demolish,or repair any structure
tt�Y� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
pje(�O than he is licensedporsuunothe provisions mf the ConneLicenseaols License Law ChapterSWIMMING POOL ELECTRIC VALUATION
d EEx0� 9(commencing with Section]000)af Division Sof Ne Business and Profenions Code) w /per ///�M���///�yyyy
W_y or Nat h70115ntpt Nertf I fthe bunsfortheallegedex lion.Any ivilpeationof OUTLETS-SWITCHES-FIXTURES )
Sm' ]031,3 by any applicant for a permiuubjects th is uo a civil perWty of .4
O n m than five hundred dollars($500).
NEW RESIDENTIAL CLIiCfR _SQ.FT. STORIES TYPE CONSTRUCTION
pm ;asowneraHheproperly, employ uhwagesuth rsolecompeumion,
1 the wnrk.end theswcmrcisnotint edurofferedfr Me Sec90N4.Businua ID IL• »
and essions Cadc:The Contract a Lew does rata ly m an owner of �7
pmperlywhubtaidsorimprovex ,ardwhodoessuchwackN ulfordwugh his
ownemployese,providedt uchimproveroemsartnotimended. iferedfimsell.If. i OCC.GROUP RES.UNITS
h wever,thebuildin mpraventent is sold within one year.fcom Ietion,themwner- I O —
builderwillhove burden of proving that he did not build or impr ve for purpose of
sale')' QTY, PLUMBING PERMIT FEF. PLUODZONE AM
[Irofthe pros perly, exc a fingwithlicrn contractional.
c duct the project(Sec.RM B d Professions Code:) a Comsacaors
Lice uLawdoesnotap lyma o r propertywhabuiidsori estherean,and PERMIT ISSUANCE
who ontmctsforsuchp conhactods)licensed pa nothe Conuxtoes ALTER-DRAIN&VONT- ATER FA
Lice se Law. ( ) FEC SUMMARY
❑ sin exempt un .B&P C for this reason OUTSIBACK ROW PROTE VICE DE MES
SANITARY YN
Owne Date DRAINS-FLOOR,ROOF,A COND. RECEIPT#
WORK COMPENS ION DECLARATION SCHOOLTAX Y N
❑ Ih mhyaffirm @aJ have eccni to ofc.nxm mxlGinnae,mraceroficetemf Fl%TURfiS-PER TRAP RECEIPT#
main.Compensation houmnc< cmifaA copy meaaf(Sec.3g00,Lab CJwhich PARK FEE Y N
coversul enid'oe'sunder lhi emit. GAS-EA.SYSTEM-I ING40UTLET RECE #
Policy# BUILDING D SION FEES
C.,. GAS-EA.SYSTEM-OVER4 PLANCHECK 3Q
❑ Cod ad co s hereby famished.
❑ Cool py is fled with the city inspection division. GRE-ASIANDUSTRL WASTE I GRAD f �n
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP S 'E
COMPENSATION INSURANCE
(This section needmm becompleted if Ne permit is for one hundred dolours(SIM) SEWER-SANITARY-STORM EA.200P1'. YFEE
or leu.)
Icetifythatimthep,rforpanmof Ne wmkfaredichthis,prinhis issucd,I shall WATER HEATER W/VCNT/ELECfR
vat employ any penon in any manner so as m become subject to the Warkcrs' PAID
Con'rosmon Lawsof Celifomia. Date WATER SYSTEMRREATING Date R
Q z Applicant
z0 NOTICE I'O APPLICANT:If,after making this Cerificaaof Exemption,yo.should NEW RESIDENTIAL PLMR. SQ,PI. TOTAL:
� In became subject m the Worker's Compensation provisions of the labor Code,you mum
, foMwith comply wiNsuch provision or this .I,shall be deemed revoked. BUILDING FEE
F CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thin inert is a construction lending agency for the pcom mance of
U O ELECTRIC FEE
Ne work for which this permit is issued(Sec.3097.Civ.CJ
Lender's Name
U.0 QTY. MECHANICAL PERMIT FEE PLUMBING FEE
Lenders Address
W1 unify a n,1 have tend itNis application and installed athe above information reletion is M[CHANICAL FEE ►�
correct.Iugreemcomply withall yaudinr countyordinancesofand statelaws
upogao PERMIT ISSUANCE
U y idow.ngcomsnucaiomert hereby purpose.
of Nis city to enter upon the CONSTRUCTION TAX
7 above-mentioned property inspection keep
ALTER OR ADDTO MECH.
G7 (We)agree to save,indemnify end keep humlus Ne City.f Cupertino against
liabilities,judgmrna,casts end expctaes which may in any weyxcme agdnst said Ciry AIR HANDLING UNIT(T010.000 CFM)
m 7usmm of the granting of Nis permit.
AIR HANDLING UNIT(OVER IO,D00 CFM)
tgnatvre of Ap anUContruc�r s Date EXHAUST HOOD(WNUCT)
PAID
HAZARDOUS MATER IMIODISCLOSURC HEATING UNIT(TO 1043,000 BTU) Date Receipt#
Will the applicant or future building occupant same or handle M1nserdous malarial HEATINGUNIT(OVER IDLOMBTU)
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)]
11 Yes ❑No VENTILATION FAN(SINGLE RFSID)
Tn
Will theapplicutor forum buildingoccuprnt uxyuipmcntordeviceswhichemit
BOILER-COMP(3HP OR 1W,000 BTU)'of ISSU�AIC�D$
srerdous an conmminants u defined by the Bey Area Air Quality Management BOILER-COW(OVER 100,00D BTU)
`° JUL 18 1995
❑Y. ❑Na NEW RESIDENTIAL MECH. SQ.FT.
I have Mail the M1aveNous materials requirements under Chapter 6.95 of the
' Califnmiu Health&Safety Code,Sections 25505,M533 and 25534. 1 understand that CITY
U G M NU
if the building does nm currently have a mount.Not it is my responxibility m notify the — -
occupant of the requirements which must be met prior to issuance of a Certificate of
Occuwscy.
Owner or uuNmiud agent Date TOTA ISSUED Y.-
OFFICE
F