26434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE
B ILU: G-ELEC'1'RI AI, PERMITNO, 26434'1
SIO N NO APPLICATION/PERMIT ICATION/PERMIT PLUMRNG-MECHANICAL.
BUILDING DIVISIOIIUII.DING I'RO,IKC'I'IDRN'1'IFICA'1'l(3N
UILg1NG'ADDDR(ES'S: SANITARY NO. APPPPL,ICATIONSUBMITTALDATE
Q U vQ UNIT# LOT
OWNERS NAME PHONE: ?71
TRACTOR'S NAME: - LICNO: N/C �D CONTROLp
zc
.HCHI I ECURNGINHER: - / LIC NO: RESS: ❑
CONTACT: .fJd/ w/'(///�� PHONE: , I?LECTRIC PERMIT FEE BUILDING PIiRMIT INFO
/✓I r L- Gt/ 4/(//
y/ BLD G T PLUMB MECH
PERMIT ISSUANCE ..G
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
Qyy Ihereby affml that l am licensed under pmvisionsofChapter9(commencingwith
❑100 Sermon 7000)of Div]si �Jufthe Business and Pmfessin s balfarmandeffect, eCod�eT,and my license is in PANELS 0 (/JGl1 Q�r6
UE
Vt<iL Datetrsc Class II Commume "O 201170000 AMPS 70 �(•(
ARCIIIT'CCTS DECIARA'TION SQ. .00R A� f/SQ.FT.
C` _Q OVER
O Z—I] 1 understand my plans shell he uuJ u public recoNa.
a�y[C..s�s - SIGNS ELECTRICAL
Y A J Licensed Professional 1
K�'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°�OaV 1 hereby eMon thm 1 am exempt from.the Contractor's License Law for the
following remora.(Section 7031.5,Business and Professions Cate:Any city or county TEMP.METER OR POLE INST. A
which rel,ir.a permit to ammrum,alter,improve,demolkh,
`/�A
or repmr any suucwre - <
E }� prinrm its isimmes,aho requires theapplienal farauch permiuo fileasigned statement POWER DEVICES
p tom he is Iicenxd pursuant to the prusmi ns of the Commerce.License law(Chapter
9(conmiencing with Section 700()ofDivision 3 ofthe Business and PinfessionsCode) SWIMMING POOL ELECTRIC VALUAn,
or that he is exempt therefrom and the basis for the alleged exemption.My violation of OUTLETS }V{/�
,_Z, Section 7031.5 by any applicant for a permit subjects the applicununocivil penally of
� G
an,momthin fee hundred do[].($50H. NEW RESIUfNT1AL ELECTR _SQ.FT.
CG ElLusowncrofthe property,ormycmployeeswith wages nstheirsolecoa,mmioa, STORIES TYPE CONSTRUCTION
will do the work,and the structure is not intended or offered for sale(Sm.7044,Business
and Professions Cade:The Comrxeoes License Low does not apply to an owner of
progeny who builds or improves lhereon.anit who deals such walk himselfarthrough his OCC GROUP RPS.UNITS
ownemployecs,pmvided Natsuchimprovemenu amnotintendMoroffemd formle.If,
bowcver.the buddingar imprlivemenl is wed within oneyearofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpox of
❑ I,:Is ownernf the Property,amexclmively contracting with licensed canlram:Lm QTY. PLUMBING PERMIT PEE FLOOD ZONE MIN
eonsuuel the project(Sea 7(44,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
Licenulsw doesnm apply m w nwnerof progeny whnhuildsorimreon,an
provesthed
who contracts forsuch projects with emntmctogs)licensed pursuant o the Contractors
license Law. ALTER-DRAIN&VENT-WATER(LA) FRESUMMARY
❑ 1 nm exempt under gee. ,B&P C for this rmson BACK FLOW PROTECT.DEVICE SANITARY TY L N
Ow Dau RECEIPT p
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPfiNSAT10NDECLARATION SCfI00L TA% Y_N
Iherehyaffirm Nal have
urance ordfmremf meant loul6insurem Lab C.) which ll%TBRPS-PER TRAP RIeCE1P1'#
WorketT Compensation lnsumncemnanified copy thereof(Sec.JN00,Lab CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT
Policy# BUILDING DIVISIO1 FFt
Company
❑ Cenifedcopyishembyfumished. GAS-PA.SYSTEM-OVER 0 EA) PLA NCHECK PEC
❑ Certified copy is filed with the city inspection division. GRIASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OE EXEMPTION FROM WORKERS' GREASETRAP SOILS FELL
COMPENSATION INSURANCE
(Unx uctionneednot hecompletedifdtepermitis for one hundred dolbsta Pi lip) SEWER-SANITARY-STORM G.2001717. ENERGY FEE
I less.)
I certify that in the performance ofihe work for which this permit is issued,l shell WATER HHATEIt W/VENT/P-LECI'R
I eat employ any Person in any manner so as as bmnme subject to the Workers' PAID
Compen...mulewsof Colifomin Date WATER SYSTEMrfRP.ATING Date Recipe#
Q z APplicum
Z 0 NOTICE TO APPLICANT:IL after makingthis Cenificme of Exemption,you should NEW RES]DENT IAL PLMIL SQ.IT. TOTAL:
te+ Cl� become subject to the Worker's Compensation provisions of she Labor Cade,you must
�. 7 forthwith comply with such provisions or Nis permit shal l he deemed revoked. BUILDING FE
NJ
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^� I hereby affirm that there is a construction lending agency for the pmfomtwce of
L) 0 the work for which this Permit is slued(.9ce. p97, CJ TOTAL: ELECTRIC FEE.
Lender's Name—IPI 5 v
LI, U Lender's Address ' QTY. MECHANICALPERMIT FEE PLUMBING FEE
1 certify That 1 have retro d, pl' ti old state that the above inforroman is
cnnect. le6grr�Ec to comply with all city d coumyordinancmand state laws helmingm PERMITISSUANCC MECHANICAL I9?P.
huilJing cnn..iructinn,unJ hereby nuthoriae repmsenwtives of chis city to emerupon the
V z above-mentioned Progeny furl don purposes. ALM OR ADDTO MECH. CONSTRUCTION TAX
(We7 agree to save, m y end keep xosde. the f in gains
Iiabilities,juJk�nes.c wd pensee whi yin rywRe it AIR HANDLING UNIT('fO IO,WO CPM)
in canxgoe it e., mnf this perm
AIR HANDLING UNIT(OVER 10,000 CFM)
Signa m f n o EXHAUST HOOD(WIDUCIT PAID
a1AZARDOUS�MATCR1ALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dae Re<eiptp
Will lheuppliennt or future buatlding occuP some or handle hand smaterial HEATING UNIT(OVER 100,'X10 BTU)
as defined by the Cupertino Munici Cafe. pier 9.12,end the and Safety
Cale,Section 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No ISSUANCE.DATE
WillNeapplicantarfuw IJigvp.ntuxequipmenmrdeviccswhichemit BOILER-COMP(JIIP OR 1(X1,000 BTU) Rl a.
nxadnm air contaminants as Aefin d by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0110 BTU) Y' A
surO7 J
ClYes ❑No t NEW RESIDENTIAL MECH. SQ,FT. UN 2 i9�
I have read the hamrdous materials requirements under Chapter 6.95 of the �Y
Colifnrnla leollh&Safety Carlo,Scnions 25505,25573 and 25534. 1 understand Thal CI)Y
if of
n ,ahemnts Which
hu Nailir myrteanceoilitymnmify me UrLUr-
nccupunt of the reyuiremems which mea Fc met prior to issuance of a Certificate of
Occupancy. '
Owner nr mloorleod agent Date TOTAL: ISSUED BY:
OFFICE
T c .� C�J�3�rU/Si aril
. /00z/U -�/y1�'Jen�al �Vei CV�r�-ntlG, Cfl .
dAj
� ® Z SpnaN'Itr •
,lury,r
21994
DLDG: INSPECTION I'.
CITY, DE F.p' uNQT� n
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ACCO � Y
p >F
fRTI c wr I1
DAT N C Df�AN`pp�i Sr T i �C
A � �
SIGN.- r s a S
This set of
lawful two en the
Oil same make a;;; < .:'t trines'n n• '7USf
the buildi 9 Delrrt , r ,,:g s n, a is n,
ThB &tarn 8 Dept., « pn;ms aerations
SHALL N�in8 of illi, C'pe,t Sion from t
aQPfovai The her .n r^ ,no
Of
Of any City �hdi�aryCE ii7 )err or to ibetigns 1+ 3� v
tate to pi :,sion
cl
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a�C14
OFFICE COPY"'
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SANTA CLARA COUNTY CONTROL NUMBER
� CENTRAL FIRE PROTECTION DISTRICT // ?
iAF �' 14700 WINCHESTER BOULEVARD PERMIT NUMBER(.
AApTtrr,oN p+�' I.OS GATOS, CA 95030-1818 (408)378-4010
SERVICE SINCE 1947 FAX(408)378-9342
PLAN CHECK N0.
PLAN REVIEW COMMENTS
CODE/SEC. SHEET NO. M
3go Ll AOL, r
r)
PU4 .
JURIS PLANS SPECS NEW REMODEL AS CONST.DESCRIP. BY EJ El 0 13 '`'�\ DATE q PAGE
SS
SEC. LOOK OCC OCC.LOAD Td.,( AREA ARCH/ENG/CONTRACTOR/OWNER
NAME OF FACILITY LOCATION
CAS v 1C V
Serving West Valley Cities of:
Campbell, Cupertino, Monte Sereno, Saratoga, Town of Los Gatos, and Adjacent County Areas