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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OFIPERTINO '- "'
BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING -NIP.c ANICAL
�a BUILDING PROJECT III WHICATION.._
PERMIT NO,
24993
BUILDINGI ADDRESS,
•`���� �` — '" UNIT♦ LOTH
SANITAKY NO.
MPUCVU NSUBMITTALDATI
taaIl-v-i
OWNER' :� _-`. PHONE:
a♦G'l_lw+'7�—
CONTRACTOR'S NAME:e LICNO:
Nf R�L•l �N ��L846
N/C
❑
CONTKOLN
ARCH 11=1FNGINEER: LIC NO:
ADDRESS; �_, �•� w- �I�� C
CONTACT: PHONE:
+<_ m:Y�•xaPax.u: sacsonr,: "'"x' ,' _;,i
QTLY. t"'y'H.ELECITUC PERMIT" ;CEEB
^-�.c*F•�a:_e:an-,ee�-.i.npd_',:. ','�. .. r: :7�
„',.;__. BUILDING PERMIT INFO'
�-RLDG
ELECT PLUMB MECII
El 1
PERMIT ISSUANCE
LICENSEDCONTRACTOR'SDECLARATION
IM17031/fDichat sed with
rifesions my
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
`J\
ening
Sutton a meon Division3 of Na Businux and Professions Code, and myliameixa
sion 3 of the Business Codr and
full force end effort.
Lic.N R S
PANELS
UPTO200AMP5 a
u Wntrecmr esscgv
ARCHITECTS DECLARATION
1 understood my plans shall No used u public records.
201.IOW AMPS
OVER 1000 AMPS
SQ IT. FLOOR AREA
Si PT.
SIGNS ELECTRICAL
Licensed Professio:ial
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 sexempt from the Concretes', License Lew for the
in
SPECIAL CIRCUIT/ABSC.
TEMP. MEIFR OR POLE DOST.
following won. (See on ]0313, Business and Pre(eWom Code: My city or cowry
which requves a pemdt m romvun, altrt, improve. demolish, o repair any sysrcmrt
Tiles suument
theepplim,ord,
POWER DEVICES
lissuaed'un on theCommrmiOo
thatLis
TNI he is licensed with
a Section 7000)
00 Provisions of Ne themm�ors and Pro law (Chapter
Code)
9 uamneiscom thSenfromandthe Division Sof the Business Bute PAny
SWIMMING POOL ELECTRIC
VALUATION
vi is
on of
or dsathcis1,5 by ,Wbeaandr abssist abets dic.,licaged tion. divil chali
Sinton applicantfarapermit subjects Ne applicant toacivil penalty of
^
17,S)
OUH.EIB- SWITCHES -FIXTURES
than re hu
mat more than five hundred dollen ($SWh
❑ I. noacncr aswithwegcautheuwla rompemaoes,
1
NEW RESIDENTIAL of FM _SQ. FT.
STORIES
TYPE CONSTRUCflOf
and Uncommo.ormyamen
will dothe siva. endmemonurtIsrael ,U ooffendfasde(Set. tore,Business
and Pofessions Code: The Cmnvactora U. Lew does rat apply to an owner of
propcnywMhildsorimprovndsercan,and whodoesauch work himselforthmughhis
oweemployers, pmvidedthat loch impmveermusre noti...rhaderoffertd hassle. If,
OCC. GROUP
RES. UNITS
eerr
h T
however. the building oimprovement is sold within one ycautdcanpiction, theowner.
builder will have the burden of proving that he did... build or improve for purpose of
a
P �y �. pL alt(G _x ..� .>- �ntr,v
pERMRISSUAN t✓s
❑ I.ssowarofdse Prop M.mexclusivel nwnin widslicenudevotraun w
..net w project (Set. ]OI4, Business and ywhobuil Code:)'Ihe Convenors
liana Lew des rot apply m an owner of property who by Ids o improve dserwt. end
FLOOD ZONE
APIA
whocmntracu fosuchpmjauwithammuscsotm i...sedpmammittothe Convenors
U. law.
ALTER - DRAIN& w6rAygm (EA) 1 Iaw 017 7,;
itp.5,Tj3-;.FEESUMMARY.;'t.'::;-
-
- -LO
❑ I atn esempt ured Sec. , B & P C fo this .
BACK DEVICE
I I
SANITARY Y N
Oww Di
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
❑ Ihueby effrm twlheve ecntifcare of canunt an"
RIf.w.ure,cr.ceatificateof
a
Warman' Compensation hoomme.m. menifed copy thereof(Sac. 3g W, Lab C.) which
SCHOOLTAX YECEIPTN N
RECEIPT#
FlXTIIRFS PER TRAP
PARK FEE Y N
vtallemphriasoderthisi iL
Policy N
GAS -EA. SYSTEM -I INC. OUTLETS
RECEIPT#
BUILDING DIVISION FEES
Company
GAS -EA. SYSTEM -OVER 4 TEA)
PLANCHECK ME
❑ CeNtfed copy is hereby furnished.
❑ Certfed wpy is TJed with the riry inspection division.
GRE xSFRNDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFlCATEOFEXEMPIIONFROMWORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
SEWER - SANITARY - STORM EA. 20FT.
ENERGY FEE
IThissation mad ata becompleted if dsepemtt isfo one hundred dollars (SI0)
odes.)
WATER HEATER W/VF.NT/ELECIR
I certify tout in the performance ofdse woe for which this permit is issued,) shall
no employ any person in any mover as as to become subject ro the Workers
Conprnwionlawsof Califamia Dau
Applicant
WATER SYSTEMfi TING
PAID
pate Receipt#
NOTICE TO APPLICANT:H, aper nuking this Canifictuof F.aemption, you should
became subject m rhe Workers Compcmatien provisions of the Lebo Cade, you must
NEW RESIDENTIAL PLAID. SQ. FT.
TOTAL:
fornwin comply wits such previsions or this permit Ndl be damned m.Wd.
BUILDING FEE r
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm But there is a construction lending ageay for the performance of
the woe for which this penvul is issued (Set. 303], Civ. C.)
Lenders Name,.
TOTAL:
ELECTRIC FEE
Lenders Address,QTY.
114' MECHANICAL PERMIT •xtA q';'IMFEB ",r,;'-
PLUMBING FEE
ce
1 certify that I have Rad his application and ann that tinbove ainf.ficen n
conal lagrte mcomply acids Jlcity and county ordinances amdsuce laws road,m
building construction, and hereby nuthorime reprrsenutives of dsiscity memer upon the
above-mentioned property for inspection purposes.
'[1` t`.`
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and kap M1ermless the City of Cupertino against
Iiabilmes.judgmcnu. cmu and nPont. which may in any way.ccrue aguttst said City
AIR HANDLING UNIT (TO I OD00 CFM)
< no of the granting Of,h penniL
in
esi
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUSTHOOD(WMUCD
Siglkhr Applic UComnctor It ate
PAID
HEATING UNIT TO Bali BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Remiss #
Will the spplicant or for. building acupant nom m handle humorous tracerial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 1011100 BTU)
Code, Section 25532(.)4
❑ yet ❑ No
VENTILATION FAN (SINGLE RESID)
WiI11Lceppli<antafmurc buildings<upanmuegvipmenmr devicca whichmtit
BOILER, COMPDHP OR IW.OD08TU)
ISSUANCE DATE
PAID
hanrdous air contonimou as defined by the Bay Arts Aw Costly Management
ITan;er'.
BOILER -COW (OVER IW,O(10 BTU)
❑ Yes Cl No
RPR
NEW RESIDENTIAL MECH.—SQ, FT.
I have Rad the hicandous materials rice iremenu under Chapter 6.95 of the
California Health A, Safety Coda Sections 25505, M513 and 25534. 1 undanund that
if the building does no currently have a man, that it is my responsibility to notify the
r
Y
e•/, /9g
I U"
LU��hI
of or requircmcnu mrim to sooner which must be et puance of s Certificate of
Jf
Ocapani
ccupancy.
ISSUED BY:
Owner or ant minced ag<m Dau
TOTAL:
OFFICE