24593APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING- A.PCT'Ift
APPLICATION/PERMIT PLUMBIKG-MtIDFNHFlCA
BUILDING DIVISION HU{LDING PROJECT IUBN'1'IfICA'I'I(1\'
PERMITNO.
24593
BUILDING ADDRESS :
SANITARY NO.
APPLICATION SUBBM�II'1'AL DATE
- /ryI /�
SLID Pod 'odCt r o UNIT# I.DTt
I/y �J.A
OW'NERSNeAMIi: ill_ �� �II�L. oD
CICMRACTOR'S NAME LICNO: •
„1 5
NIC
CONTRROL#eafflII
ARCIIIT'I!CI'/I!NGI ?I°R: LIC NO:
ADDRE
"5 LrlvV,?/w of .Z _S'Cial
CON 'I'nC'I': PHONE:
Q9 -Y. ELECTRIC PERMIT FEF;
BUILDING PERMIT INFO
BLIXI ELECT P1xUMB MECH
PERMIT ISSUANCE
El E ICV El
LICENSED CONTRACTOR'S DF.CIARATION
Ih7000) ofrmision 3mliccnmlunssAnd isinnnofni Coke 9nd mmecense with
Senium lIXp)of Division Sof the Business wJl'ndnssinm Coke. and my license is in
full formandc bt. - -
I.Iccnxc n '- n Lic.0 � I
Dae - Comroc��A tutu '+i k-4TV3,YJ
ARCHITECTS DECLARA'T'ION /
I understand my plans 0.11 be used as Public records.
APPLIANCES - RESIDENTIAL.
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LOB DESCRIPTION
����^ s �� �, ,
1
PANELS
UPT02MAMM
201-1f AMPS
OVER IOW AMPS
SQ. IT. FLOOR AREA
$/SQ. FI'.
SIGNS ELECTRICAL
j.H
Licensed Professional
OWNER -BUILDER DHCIARATION
I bennby affirm that 1 ata exettgn Tram the C .... thorax License Law for the
SPECIAL CIRCUIT'/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
jY�
1 O
;off
:KSection
iSp
'1-'p
��ZL
Iidlowing rcmon.(Scction]031.5, Business and Pmfcssio is Code: Any city or caunly
which requims a ptmit to coostruc6 alter. Improve, dental kh. or repair any structure
prior to he issuance, also requires the applicant for such permit to file a signed statement
that he is licensed purauunt to Ne provision of the Camrarmrs License Isw (Chaprer
9(commencing with SectionT00(YofDivision 3 ofthe Business and Professions Code)
or that he is exempt herefrom and the Of for the alleged exemption. Any violation of
7031.5 by any applicant to. permit xubjm,.,hA applicant or acivil Penalty of
not mom than five hundred dollars ($500J.
❑ I,asownerefthepmpny.ormyemploy swithwageaaxtheirsolecompensation.
will call ahok,and the structure in not intended orodfetM fofsuie Set. Business
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
NIiW RESIDEMIAL ELECT# —SQ. FT.
STORIES
TYPECONSTRUCUON
and PrufeaMkw, Col The Contractor's License Law J«a not apply to An owner of
puppy who buildsarimproves themon.and albi such work himseforthrough his
on emmfe
ployees, provided that such not meadalor offered formic. If,
OCC GROG P
RES. UNITS
In FAL:
however, the holding o, improvement is sold within one year of errant am, thcuwnv-
builder will hove the burden of proving that he (lit] not huild or improve for purpose of
ala).
❑ I, as owner of the propny,um exclusively contracting with licensed contractors o
1:1.001) ZONE
MIN
QTY. PLUMBING PERMIT FEE
construct the project (Sec. TMd, Business and Professions Crede:) TLB Contractor's
License Law ares not apply to an owner of propry whit bui lda or approves thereon ,and
PERMIT ISSUANCE
wm
art corab fin such projects with acanuactor(s) licemaf ponuant to the Conttactolx
[mite Law.
ALTER (EA) )
FEE SUMMARY
❑ 1 Am exempt under Sec. . B A P C for this rtmoa
BACK PLOW PROTECT. DEVICE
OUTSIDE PEES
Owner Date
DRAINS -t100R.ROOFA )
.�
SANITARY Y N
RECEIPT#
WORKMAN COMPEIO CLARAON
NSATN DETI
SCH O Y N
PI%TURFS- PER'fRAP
• IM1ertby a[[irtn thanlhawaanifcumof ronxenuoaelLinava. ora ccnifimm of
Workers Com Pefi.Ohio I havnmora culari .noon1 self -i me.or. Lab CJwbieM1
R
RECP-IYI'#
P N
GAS -EA. SYSTEM-] INC. L '.
vers all crnY+ eajupW l� -
Rdicy # _! "1 -k i
RECEIPT#
B ILDING DIVISION IBES
Compnn �i_t-T fc rT hrL
y
GAS - IiA. SYSTEM -OVER 4 (li
,
iCK Plil'
, PEIi
❑Ccnilicd copy ix hereby fumishcd.
Cenified copy is filed with the city inspection division.
y]/TRL
GRGSFJINDUS STF.IN7151RC1iYI'
CERTIRCATEOFEXEMPITONFROMWORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS PEE.
SEWER - SANITARY -STORM EA. 200l
ENERGY THE
(nal mctim need nm be compincd ifthe Permitil patua,huMrcddoilass(SIW)
or less.)
WATER HGTER W/VENDELECR
I certify that in dupefmmance ofthe work for which this Permit is issued, I%hall
In
not employ any pecan in any m As to become subject to the Workers
Conspenxafionlatwsaf Cdifomiu. Dam so
Applicant
WATER SYSTEM/fREAT[NG
PAID
Date RecciptA
NO'I'ICH 'IU APPLICANT: If. after making this Cenifcam of Exemption. hu should
become so bjcO if, the Workers Compensation pn+vi.sions of the Labor Code. you must
NEW RES] DENTIAL PLMB. SQ. it'll
TOTAL
BUILDING THE
tbnhw Oh comply with such provisions or this permit shall be deemed revoked.
SEISMIC PEP
Q
CONSTRUCTION hIiM)ING AGI,NCY
z
0
F
U
CCommit.
,,F
,'L
I hereby allirm that there is a constractirtn lending agency for the performance of
the work for which this Perm, is+ss.W«
(S. 3091, Civ. C.)
IcnJce, Name
^
TOTAL: �y .v
ELECTRIC ITIS
Lender's Addrev
QTY. MECHANICAL PERMIT FEE
PLUMBING PGC
hr
a
I mrify that I have read this application and nate inat the aMwe information ix
l agree to Comply with all city and county ordinances and nam laws relating to
building conxwction. and hereby Authorize reprtmmatives oftnix city menter upon the
vbmc-mcntionN property for inspc ton f purpose%.
PERMIT ISSUANCE
MECHANICAL PEE
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
(We) agree tomsave, indemnify and keep hvrmlcxs the City of Cupertino
liabili' jyJlpnems,custxa expo. M1ic mayinany way accrveagainat said City
s id City
AIR HANDLING UNIT (TO 10,0(KI CFM)
in not n+ft c, ni 8 ftti
�� L G
AIR HANDLING UNIT (OVER Ill CIM)
li%IIAUS')'HOOD (W/DUCT)
PAID
Si ,m nl Applicu memo Dam
IIEVI ING UNIT (TO 100,0110 BTU)
Date Receipt
HAZARDOUS MATERIALS DISCLOSURE
Wil l the applicant or future Aoildingoccupum xmmor handle haaardme, mu¢nal
As defhled by the Cupertino Mmucipl Cad, Chapter 9.12, And the Health and Safety
HEATING UNIT (OVER 100.000 HT'U)
TOTAL
J
CMc, Section 25532(u)R
El Yea ❑ No
VENTILATION FAN (SINGLE RESID)
Pp a«cupan q pmcn
Will taco ntainmrfuture derinn BAYf Al t orded«ranagement
h mous air comamirunts m dcfncd by the liay Ama Air Quality Management
Dieu cTl
NOILF.R- COMP (JHP OR IW.(00 RTU)
ISSUANCE DATE
1� A 10
Ir
BOILER - COMP (OVER 10J"(IfI BTU)
11 YO, 13No
I have read the hmardous maerials rtyaimmcntx under Chapter 6.95 of the
JAN Y - 6 1993
NEW RESIDENTIAL Ni SQ. F1'.
Califomia Ileulth A, Safety Code. Sections 25505, 255)3 And 25534. 1 undrnund that
Asst
itthe hailding dou ur
not cremly have A tenant, that h is my rcxponsibilaymmaify the
occupant of the rcquitanents which must be met prior m ixxnance of a Cenincale of
I i
V L1Y l IG Gf
Occapuocy.
ISSUED BY:
Owner to outhadoed agent Dam
TOTAL:
OFFICE