24921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELERICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CHANIn A 1
BUILDING PRDJEGI'IUEN'1'IFICFICA'1'ION L Lf G 92
BUILDING ADDRESS /tic��s..� U SANITARY NO. APPLICATION SU_BMI�TTALL�DATE
'0 f �'�• *-A I f� UNIT �" 1 LOT# 02 1
OWNERS Mf:: PHONE: CONTRACTOR'S LIC LIC NO: ���+++ ��'V
nc�Gpp.ii r N/C CONTROL#
ARCHITECF/ENGINEER: LIC NO: ADDRESS: - PfO ❑ 1�; ,
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
D DGEL ECIj PLUMB MSCI
PERMIT ISSUANCE _a /f,LjJ[\�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby affirm that l am licensed underpmvinionsof Chepmr9(commencing with
1100 Section IIg#Baf Division Sof the Beeinessand Professions Code.and my license ism PANELS
FF ttou ruu rmae arta erceN.
QLy IJmnse 1 IcTa
Lm# UPT0200AMPS �� I
y6a Dam.�Cammmrr _Cc&A2[6GTaJ 201.["AMP5
Fyz ARCHITECTS DECLARATION SQ.Irl',FLOOR AREA S/SQ.IcI'.
ZO.is— OVER IOWA SAV
OZ-0 I understand my Plans shall be used W public recoNs. \
r,2 /+ r gk fz SIGNS ELE 1A � C6... 3N
ha mC� Licamod Profeommil
m< OWNER-BUILDER DECLARATION SPECIA JC.
�?a I hereby arcirn that 1 am exempt four the Contractors Liomae Law for the v, 11`.dll a Ili—
iyu.y¢ following rcaaan.(Section7031.5,Business and ProETE
Professions Code:Aaycityoscounty TEMP.MR LE INST.
E:0 J which reyuirea a permit m comwct,alien impmvq demolish,or repair any swcwre
'�}� mics issuance,almre Thee ]imam farsuch Ira flea si ncJ statement POWER DEVICI
uu�J prior quires PP Permi g
y�j rG�Os that he is license)pursuantmthe provisions of the Camracmr'a Lieenx lww(Chapter
n eq 9(conunencing with Sectimn 7lXKq afDivisionJof the Business and Rnfesaions Cole) SW ING POOLCBIC AI. ATION
❑y or that hcisexempt therefrom and the basis for alleged exemption.Any vinlarionof N, /\�)V�
k.Za Section 7031.5 by any applicant far a permit subjceutheapplicant m e civil penalty of S-SWITCfIFS-FI%TURES Six
,Y�V
not mom than five hundred dallvrs($500).
00 ❑ I,nrownerofthepraperty,ormyemployeeswithwugesmtheirsolecompensation, NEW RESIDPNTIAI.ELEC[R _SQ.IT. STO TYPE CONSTRUCTION
L e22 will do thework,and theawnurcirnot imendedoro(farm formle(Sm.70 ,Business
and Prefeasmas Cade:The Contractors License Law does not apply m on owner of
prapertywh ilimIdsarimpmves therean.and whoJo,such workhlmxclfor Ihmugh his
ownemployms,providcd that such improvements ort natimendedandfercdforsale.IL OCC.GROUP RES,UNITS
however,the bmidingor improvement is sol)within one yeaofcompletian,the owner- L
builder will have the burden of proving that he did not build ar improve for purpose of
Ee')' PLUMBING PERMIT FEE
E] 1,asownerafthepropeny,eta exclusively convecting with licensed contrecmQTY.
nm F1000'LONE APN
common the Project(Sea 7044,Business end P ofessmax Carl The Commcare
License Luwdees napply to an ownerafpropeny who builclsorimpraves daman.and PERMIT ISSUANCE
m
wM1acormacta for such projects with a continuants)licensed pursuant tothe Contmcmrx
License Law. ALTER-DRAINffi VENT-WATER(EA) -"� FEESUMMARY
❑ l um exempt under Sec. B ffi P C for this reason PACK FLOW PROTCCT.DEVICE =Si - ,1
SANITARY V N
Owns Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.GOND. SCHOOLTAX YN
❑ Ihemby affirm lhatihavevcmnificme nfeonunno self-insure,aro cenifcSa of Fl%TURES-PCR TRAP `� RECEIPTp
Wotken'Compensation Imumnm or v certified copy thereaf(Sm.3ftW.Leb CJ which PARK FF:H Y N
covers all employee's under this permit. GAS-FA.SYSTEM-I INC.4 OUTLCIS �n RECCIPOp
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEMOVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenified ropy is filed with the city impaction division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF E%CMITION PROM WORKERS' GREASP.TRAP SOILS ME IL
COMPENSATION INSURANCE
(Thix union needo.,be completed iftM1e permit is for one hundred dollars(SIW) SEWER-SAN19'ARY-STORM EA.200PT. ENERGY ME
or less.)
I certify that in the perfornexae of the work for whichthis permit is bared,I shall WATER HEATER WNHNT/ELECIR ��
not employ any person in any manner ao as to become subject m the Worked PAID
Compensaioniswsof California. Date WATER SYSTEM/REATING Data Receipt#
Q Z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLM B. SQ.FT. TOTAL:
Fbecome subject the Worker's Compensation provisions of the Labor Code,you must
a forthwith mmPly with such provisions or this permit mail be dimmed revoked. BUILDING FEF,
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEB O
U z 1 hereby affirm Nvuhere is a consrn
uben
n leading agcy for the pe,f.n.of
O the workfar which This permit is issued(Sm.3097,Civ.C.) ELECTRIC E
lender's Name
D" F Lenders Address QTY. MECHANICAL PERMIT FEE PLUM G E
RJ
U I certify that I have read this application and state that the above information is ME ANI L FE
C."E agree to comply with all city and county ordinances andstamlaws relvtingm PERMIT ISSUANCE
"'tea I
[^" building consvunion,end lieuby nmhariu representatives of this city menteruponthe CONSTRUCTION TAX
U above-mentioned property,for inspection purposes. ALTER OR ADD TO MECH.
(We)vg.m save,indemnify it keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses whichmay in any waystatowagmest said City AIR HANDLING UNIT(TO 1x,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT LOVE R I(L0W CFM)
Signature of ApplicenUCnmmctor Dae EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEAT ING UNIT(TO 100,003 BTU) Dale RaeildN
Will the applicant or future building occupant Wore or handle haurdous material HEATING ON IT(OVER 100.000 BTU) TAL'.
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 VENTILATION FAN(SINGLB RESID)
❑Y. ❑Na
ISSUANCE DAVP
Will Ne applicamorfumrchaddingoccupam useNuipmentordevices whichemit BOILER-COMPOHPOR 100,0000111)
hazerdom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW,004)BTU) 'ff [� ' D r
Dlavic@ P A
/ ❑Yes- 0 N NEW RESIDENTIAL MECH.—SQ.FT-
I
TI have read the huurdous materials requiumemr reader Chapter 6.95 of the "PAQ WN r- AUG 2 51993
California Health ffi Safety Cade,Sections 25505,25533 and 25534.I understaW Nat
if the building docs not currently have a amoa,That it is my responsibility m notify the
mpunt of the rcquiremems which must be met prior m issuance of a Certificate of Ur )II
Occupancy.
Owneroramhod dagcm Date ISSUEDBY:
OFFICE