26587/ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V
CITY OF CUPF.SION PERMIT NO, 26587
BUILDING DIVISION APPLICATION/PERMIT PING PROD CPADEN NICK
BUILDING YN(IJ4 CI'IIIBN'TIF'ICA'I'ION
BUILDING ADDRESS: /L� �� AD (D Sl
SANITARY NO. APPLICATION DATE
2 J UNIT, lU OTp ��
OWNI3RS NAME: PHONE: CONTRACTORS_ & ' NAME: •�vZLI/C N•0/(:1,�15VIC CONUROLp
•ARCIIITECT/UeRNNEFR: LIC NO: ADDRESS:
C'
D1Ii'T ❑
CONTACT: PHONE
v
ECH
�' //TA`: �\ ����y�.}��aL,a�.,p� ��F l/�r. QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
F-1 4109 VDU--ter' E �•a I'o F.{, PERMITISSUANCE 'L-m B� �0 UMB Mme✓
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Wim\ (�
n=z Ihimbyafnat Net l amlicamead underprovisions ofatipler9(commencingwiN JOB DESCRIPTION
qCO gout- Po11force aandaffect�tsion3of the Basin•as and Professions old my license is in PANELS
QQ UUy) LicenseC Lm..S 6 VV IIP TO 200 AMPS
y Dale Conwcmr r� 201-IBM AMPS
zOyZ, ARCHITECTS DECLARATION SQ.FT.FLOORAREA $/SQ.FT.
OZ-0
1 understand MY plans shall be used M public recoils. OVER 1000 AMPS
P` W SIGNS ELECTRICAL
iiaof Licensdertby nffinnl th0a-Nem UILp R DECrom RATIOim'a License Law for the SPECIAL CIRCUIT/MISC. ,.. 1 (�
d 3�m following reason.(Section 7031.5,Business and Prof esiov Code:Any city or county TEMP.METER OR POLE MST. /l •O`-'T
r=��� which m,fd es a Permit to construct,alter,improve,demolish,or repair any suracere "`��� 1
Nts�>- #norm its i....ace,alm requires the applicant formch permit to filen signed agement POWER DEVICES -
Etno that he is licensed parsuanTto the Provisions of the Contractors License Law(Chapter
9(commencing with Section 70MEof Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
LL1 L•',m or that he is exempt themfmm and the basis for Ne alleged exemption.Any violationof
tZ¢ Section 7031.5 by my applicant for a permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FI%TURES
� G not more than Eve hundred dollars(5500). NEW RESIDENTIALELECIR Q.FT. 10� •'lg STORIES /TYPE CONSTRUCTION
W ❑ omown rive hu proddollar S50f.oy«.with wagons Neirmlecompemedon,
L will do the work,and the structure is not intended coefficient for mle(Sec.7044,Business
and Proftuiem Code:The Comrvcmr's License Law does not apply to an oworried
progeny wbobuildsmingmm.themon,mdwhodommuh makhonulfinfaoughhl. OCG GROUT' RES.UNITS
employees,provided thatsuch improvemar
entse nor menm
dedoffreat ficume.IL
however,he buildingm improvement is sold within one yearofcompletion,throwner- TOTAL: T�
builder will have the burden of proving gat he did not build or improve for purpose of l
sale.).
❑ I,as owner ofthe propeny,am exclusivclycanvacdng with licensed contractors to QTY, PLUMBING PERMIT PER: FLOODZONE APN
consumer the project(Sec.7(144,Business and Professions Code:)The Contractor's
License lawdocs not apply to an ownerofproprny whobuildsarimprovestherson,and PERMIT ISSUANCE Z
who contracts for such projects with a contractssHisen°ssed purmard tothe Contractor's se Law.
License
ALTER (EA) FEB SUMMARY
❑ ut um exempt under See ,B&P C for this nation TSID:F:E;
BACK FLOW PROTECT.DEVICE
SANITARY YN_
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm Net l have a certificate ofcomem to self-insure,or a certificate of FIXTURES PER TRAP PARK
Workers-Compensation lnsuranceoracrnifidcepythercof(See.38W.UbCJ which PARK FEE Y N_
omecostill employ«'.under This permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RCCEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(PA) PLANCHECKFEE
❑ Certified copy is hereby fumishd.
❑ Certified copy is filed with the city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ISE
COMPENSATION INSURANCE n
Oniaseetim,need nm be completed ifthe permit is for o«hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE .LA•
or less.)
I certify that in the performance of the work for which Nis permit is issued,i shell WATER HEATER W/VENT/ELECTR
not employ any pa.in my manner to,as m become subject to Ne Workers' PAID
Compensation Lmm.fCalifomia. Dae WATER SYSTEM/IREATING Date Receipt IT
O z Applicant �a
2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. i x l TOTAL:
t" I,) became subject to the Worker's Compensation pmvisiens of the labor Code,you must fp,�i 7 forthwith comply will Such Provisions or this permit shift he d« minded. BUILDING PEE ` G
1 (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
VZ I hereby affirm that hem is a construction lending agency for Ne pinfmmarnc,of TOTAL: ' ELECTRIC FLEE '
O the work for which this permit iS issued(Sea 3097,Civ.C.)
Lenders Nome
Landers Aress QTY. MECHANICALPERMIT FEE PLUMBING FEE 2
IU2-I1 certify that I have read this applicnkm and semove that the ove information is
correct.l agree to comply with all city and county ordinances and amt laws=lacing to PERMIT ISSUANCE 2 MIiCHANICAL FEIi
bulliingromvucdon,and hereby autherise repregti
srnvesof Nry m iscimorainal the
y movememimmed rt for ins tion ses. ALTER OR ADD TO MECH. CONSTRUCTION TA%
U z Property Pec perp''
(We)agree n save,indemnify and keep may in s the Circe Capron.id City
liabilitiu.judgments.costsmdaPenxswhich may in my way memeegeinst amid City AIR HANDLING UNIT IT 10,000 CFM)
ncabf the grantin of this NJ I.
Z'F AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/C tmanr ere EXHAUSTHOODDVMUC) PAID
HAZARD( S TERIALS DISCLOSURE HEATING UNIT OPO IN,"BTU) Date Receipt#
Will the applicant or fug riding occupant nom orhmdle hmvdnua maedel HEATING UNIT(OVER 100,000 OTU) TOTAL:
sidelined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 VENTILATION FAN(SINGLE RESID)
❑Ye. ❑No
ISSUANCF.DATE
Will theapplicant rfutumbuildln fusee memordeviceewhichemit BOILER-COMP(3HPOR 100,000 BTU)
!by the yea
hazardous air contaminants az defind by the Boy Area Air Quality Mmmgemcm BOILER-COMP(OVER 11%1,000 BTU)
District? ID yes ❑No NEW RESIDENTIAL MECH.
7ffPESQ FT. O •'1 OCT 12 1994
I have read the hazardous materials rcquiremems..or,Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that rsl l� UR I'U Lh I Au
i(the building does not rimae lc Investment,that it is my respomibility to notify Ne v
occupant of the requirements which must be,met prior to ismaneo of u Certificate of
Occupancy.
Owned in clam ized agam Data TOTAL: /_5_e ISSUED BY:
OFFICE