24746 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CPCYEADDRESS
ERTINO IsII.DI\.-ELLCTRICAI. PERMITNO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL. A A
BUISION
BUILDING PRf1JEC1'IUE\fIFILATHS 4 LF
BUILDING A SANITARY NO. APPLICATION SUBMITTAL DATE
Idw CsTi4T0s /-r UNIT# LOT# 2-r-Yj
OW SNA Fi: PHONE: CONI ACTOR'S NAME LIC NO:
Q/ .2-4 N/C CONTROL,p
��733 wJ rJakre+ L cc s u
' VR HITECDENGINEER: LIC NO: ADDRESSEl:
6cIS 5Rril o.4rc Awe- YKob
CON'T'ACT: PHONE: BUILDING PERMIT INFO
- QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB McE-C�H
PERMIT ISSUANCE ❑ ❑ T
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
pyz Ihercbyaffinn thmlam licensed underprovisionsof Chapmr9(commenekngwah
[+CL[) Section AKl(B of Division 3 of the Bminess and Prul'v,mrs Codc.an^y license is in PpNLs1.S
TUU TUR mrceund of r. �i f U 5is
y6y DataLican Cygif ss _ J G CoLucnt#ractar-(CII J H NTheai/1 2BIUP�T200 AMPS
I000 AMPS rY2�k,elC�
Z O'z A WITECTS DECLARATION OVER I000 AMPS Q F R $/SQ.FT,
O Z o,O I understand my plans droll be used as public records. G--a
F j SIGNS ELF,CfItICAI. k�
Licensed l'rofcssinnal E
�y.1✓=Q
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W1 hereby affirm that I am exempt from the Cosions o License law for the
'1 Lta•m following reason.(Serino 7031.5,Business and Professions Code:Any city or county "1'EMI'.METER OR POLE INST.
F u-0< which marinas a permil to recollect.alter.improve.demolish,or repair any structure 7E
E°'}5 prinnoitaissuance,also rebrires the applicant for such permit to fileusignedmatemew POWER DEVICES
ty�j C 0O that he is licensed pursuant to the provisions of the Contractors License Low(Chapter
as 9 with Section 7")ofDivision]of be Business and Professions Can,) SWIMMING POOL ELECTRIC
(commencing xi Y V ) ON
W_m othmM17031.5byanyrecruit rcfromorforthe basis
ermitsrtheal legal exemptttoaciAny 1parraionof OUTLETS-SWITCHES-FIXTURES .� `0,L
E Z a Section]Ol l.5 by any applicant dor n permit subjects the applicant a civil permhy of
nm mme than five hundred dollars($500).
C � ❑ LaxnwnernDhepn' n y p y g pensalion, ER�ID�TIALELEM 5 .FT.
pc y,orm em to ceswith wa es avheirselecom Q STORIES TYPECONSTRUCION
i3— will do the work,andme structure is net inecndelwOffered forsake(See 70ta,Business
stud Prefcsiom Code:The Comercu''n License Law does net apply 1a on ewnef of
property who builds or improves thereon and wh rdocs such work himself m through his
own employees,provided that suchimprovemcnts are not intendederoffrrcd forsale.If, OCC.GROUT' RES.UNITS
however,the barldingor improvement is sold within one yewofcompletion.the owner- TOTAL
builder will have the Nuclear of proving that he did not build or improve for purpose of
sale.).
❑ 1,uownerofthepmperty,umexclusivclyeanuactingwithlicenscdconnacionto QTY. UMBINGPERMIT FEE OCODZONE APN
nonsinuct the project(See.]M4,Business and Professions Code:)The Commemax
License Luwdocs not apply to anownerofpfopeny who builds or improves therroa.and PERMIT ISSUANCE
whecootractsfor such projects with acontmemr(s)licensed pursuant to the Contractors
Lknove Law. ALTER (EA)) FEESUMMARY
❑ I am acmpt underStt. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDP FEES
SANITARY Y N
,owner Date RECEIPT'#
\ WORK MAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND, —SCHOOL FAX Y N
❑ I hereby affirm that l have a ecnilicote of consenuo self-insare,oracertifscateof FIXTURES-PER TRAP RECEIPT#
Wiukers'Comw
petion Insurance oramnificd ropy thereof(Stt.J81X1.Lab CJ which PARK FEE YN
4I7.4 -fivers all cmplyy 's�p<Iwyt':�gme1 �{, / GAS-EA.SYSTEM.1 INC.4 OUTLETS RECEIPT p
ti,1 Policy# /� L /r0 J O Z (
BUILDING DIVISION FEES
D Ccrany - ed' ✓—� - GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Certified copy is bcrdbyth the city
Certified copy is flet with the city inspection division. GREASFANDU$TRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
('ITtisxectiun need net he complete)if the permit is[or one hundred dollars($100)
m less) SEWER-SANITARY-STORM EA.200 p. ENERGY FEE
I certffy that in the performance oflha work for which thix permit is issued,Ishall WATER HEATER W/VENT/ELECFR
not employ any person in any manna(so 10 become subject to the WorkersPAID
Z Compensation laws off 'fo �y(1,� WATER SYSTENUTREATING Date Recciptp
Q Applicant
z O NOTICE TO APPLICANT:If.after making this Certificate of Esemplion,you should NEW RESIDENTIAL PLMR. SQ.FT. TOTAL
Hbecome subject to the Wader's Comper,inow provisionsof the Labor Cede.you ace,
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the performance of
L) Q the work for which this permit is Issued(Sec.309].Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name /
O F Lerdcrs Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this applicatilamon and sthat IM1c above information is MECHANICAL FTE O
F 9L. correct.l agree to comply with all city and county ordinances and state laws mlaling to PERMIT ISSUANCE
0 building construction,and hereby oullorimreprcscnmtives ofthiscity tnentcruponthe J
U Z above-mentioned property for inspection proposal. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep harmless In City of Cupertino against -
Iiabilities,judgments.costs and expenses which may in any way accrue against aid City AIR HANDLING UNIT(TO 10.000 CFM)
in canuquence of the granting of this permit.
AIR HANDLING UNIT(OVER 10."CFM)
Signature.(Appiie.w/Contmctor D:nc EXHAUST HOOD(W/DUCT,
PAID
HAZARDOUS MATERIALS DISCLOSURE t HEATING UNIT(TO IM.W BTU) , Date Receipt#
Will the applicant or Of...baJaingoccupant uI aer handle haaacdeusmammal
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0100 BTLA TOTAI.:A p
Code.Section 25532(a)7
El Yet 1:1 No VENTILATION FAN(SINGLE RESTD)
BOILER-COMP(3HP OR 100bb0 B UU ISSUANCE DATE
Will menpphe:mrnr ratarenaileing eepapam trsee9aipmentnmemeeawnieh emh � ) L w u
6azarJeud air corwarinanp u def by be Bay Area.Air Quality Management BOILER-COMP(OVER 100.004)BTU))
.'DillrieRd FEB , 41993
h1
„mss', NEW RESIDENTIAL MECH. SQ.FT.
a\ 1 have read the I'loodnus material,receircments under Chapter 6.95 of the
Califomia Health&Safety Code,Sections 25505.25533 and 25534.1 understood that CI�Y VI v, LLltt uvy
if be building does nor recently have a tenant,that it is my reaptmsibility m notify the
veupant of the rcyuircmems which must be met prim or oweance of u C,mEvom of
Occupmmy. 000
Owner or uuNenud ii'm Data TOTAL:
6- (7Q ISSUEUB 7tL.(/CIC.
OFFICE