24747 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO - BUILDING- I,.CI'RICAL PERMITNO.
APPLICATION/PERMIT PLUMBING,-MECHANICAL /N
e BUILDING DIVISION BUILDING PROJECI'IDF:NI'IFICATHIN L
BI�ILDING ADDRLSS: SANITARY NO. APPLICATIONSUBMITTALDATE
\ x
04 a i AesrEn a UNIT# LOT# -S qA
0 °R3 NAME: PHONE: CONTRA R'S NAME: LIC NO: J
V �S9 .127 '� -I, n AtSY. '�7S �)' N/c cGN1'ROLa
ANCIIII IiCT/11JGINLER: LIC NO: DRESS: -
�uS-14�*n o i� ,,.egue6 ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
QTY. - ELECTRIC PERMIT FEE
r — BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIUfdYI'IM. JP'
I hereD affirm that l nmlicensed under isionsof Cha mr9(commencin JOB DESCRIPTION
p00 y prd p eis ih
�i100 Section 7000)of fNvisinn3ofNe Business and Pmfcxsinm Code,and mylic<nm is in ppNE1S
full force and off�`h � N S
' �J' ^
F�,W Licerr�t(See Cl ex `' �� Lic.# .2 UP TO 2W AMPS
J1<0.so
Eo
fS ' V�L Confru =/_t.[t�SSLi_y�µ#L 201-1000 AMPS
Z0
h-
ARCHITECTS DIiCIARA'1'IONOVER 1000 AMPS - ^ $Qa(;T.EL1O�EA $/SQ.PT.
OZ ❑ l understand my plans shall be used as public records. {y_� '
rH IL SIGNS EI.F.CTRICAL. 16JV T E R
Lianxd Pntexsinnal '
OWNER-Bempt?R DECLARATION SPECIAL CIRCUIT/MISC. C 01M)
OaFUF. I hereby n.(Se that 1 am exempt from the Professors
License Law for the
�+fLy which ngmeoaermiion7n3L5, t,ainosand Professions Ca de:Anycity orcoumy TEMP.METER OR POLE INST.
which requires a permit re construct,alcor,improve,demolish.t or repair any armature
or 0 he,
slicensede,ostarmoi,he mi,i..not the Co trnnino ril�Lice seLed aammeer POWER DEVICES
mKOpC rM1et he is licensed pursuant mthe provisions of the Conuacbrs License Lew(Chapter LXCLL 9(commencing with Section700d)of Division3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ty�y or that he is exempt hemfrom and the holo for alleged exemption.Any violation of OUTLET'S-SWITCHES-FIX'NRFS
Z Q Section 7031.5 by any applicant for a permit subjects the applicator no a civil penalty of
t more than Eve hundred delta.($500L . .
W � mm❑ I,asownerafthepmo ny.ormyemployecswithwagesastheirsolecompens I. a' NEW RESIDENTIAL ELECIA S QIn'. STORIES TYPE ONSTRUC ION
L will V thework,ao lb: no Contractor'.
Umme Lawreoesno,spot,to im Bons of
and 14ofcxli ons ldsde:The Commnor'x License Law Jnea not apply to an owner of _
monerty wbees.provided
that sucheram,and whtsm ea such tudedc mxlfor@rongh his
however,thebuildigori prove ant is sold
rene imendedoraffemd torsade.If, PCC.GROUP RES.UNITS
�uilder ,will
buildingorden of emcm ishan within oneyearofcompletingthe owner.
b le.). ill hive the harden of that he did not build or improve for x of TOTAL:
proving P purpose
sale.).
❑ 1,as nwnerofthepmpcny,amexclmivdycontrectingwith licensed contractors to Qom' PLUMBING PERMIT FEE MOOD ZONE APN
mvmen the pobject(See.7094,Business and Professions Code:)The Conwe9rs
Licenx Lawdoeanor applym on ownerafpmpeny whobuildsorimproves Nemnn,and PERMIT ISSUANCE
whocommgs he such projects with a communes)licensed pursuant orhe Comrumte ALTER (IiA7
I.icenx Law. FEE SUMMARY
❑ I:un exempt undo Sec. B&P C for this masonI
BACK ITAW PROTECT.DEVICE
SANITARY Y
Owner Date DRAINS-FLOOR,RWP,AIiIiA,COND. RECEIITa
WORKMAN COMP17NSAT10N DECLARATION SCI1001,TAX YN
❑ Ibcrchy nfnrm lhntlhaveecenincum of consent to self-insure,nracenilicme of FIXTURES-PE TRAP RECHurra
Wo.ken'Cotnpensationlnsumncenraccnilic copytoreof 5 380B,Lm CJwhich PARK HE Y N
Puen vll empl)#}��y, thi r .G GAS-EA.SYSTEM-I INC.4 OIl1'LETS RFCEIPTp
licyp •`' BUILDING DIVISION FEES
Company Ttil iL GAS-EA.SYSTEM OVER 4 EIA) � PLANCHECK FEE
❑ Certified copy is hereby furnished.
Sal Certified ropy is filed with the city inspection division. GREASERNDUSTR,WASTE INTERCEPTOR GRADING FEE
'\ CERTIFICATE OF EXHIAMON MOM WORKERS' GREASETRAP SOILS HE
COMPENSATION INSURANCE
Old,section need not be completed lithe permit is for one hundred dollars IS[do) SEWER-SANITARY-STORM IA,200FT. ENERGY FEE
or less.)
I certify that in rhe pertommnce ofinework fnrwbichrbis permit isisxued.l shall WATER HEA TER W/VHNT4!I.ECI'R
,at employ any p,nm in any manner an as to become subject to the Workers' PAID
O z Conlpeet^minn Lnws of Culifnmia. Dole
c WATER SYSTEMff IllINC'
PP Dere Receipt
C)
NOI become[CIL TOAPPLeWork If,afmrmnottiothis Certificate
sof of Labor iode,yshould NEW RESIDENTIALPLMN. SQ.111'. TOTAL:
V) tombmex cudidyect to the Worker's Compensation ermisinallheeemedeodgyon must
> fonhwithromplywithauchprovisionsofthispemritehellbedeemedmvoked. BUILDING FEE IS- 00
W .
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm thatthem is a construction lending agency for the Nifamrece of wTOTAL: ELECTRIC FEE
0 the orkfor whi,h,hix permit is issued(See.3097,Civ.C.)
1der's Name PLUMBING FEE
U <n
1 <ndses Address QTY. MECHANICAL PERMIT FEE
I certify that I have read this application and mate that the above information is
cor.set.la,mcto comply with all cityand county unit nancea and stare laws relatingm PERMIT ISSUANCE '� QQ MECHANICAL FEE Sa
�-t building construction,and hereby authorize represemmiveaolthis city to enter upon the
V above-mm�tinnnl Property for inspection pmryucs. ALTER OR ADII'I'0 MHCI I. CONSTRUCTION TAX
(We)agree m save,Indemnify sad keep In....Ime,the City M Capenino against
liabilitiex,judgn¢ms,costs and esparto which may inanywaysimnanagainat said City ATR HANDLING ON]PTO 10,000 CFM)
in consequence of rhe grmting of this .it.
AIR HANDLING UNIT(OVER 10,M)CFM)
Signatum olppplicamUontmcmr Date EXHAUST HOOD(W/DUCO -
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"HTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous mamriul DILATING UNIT(OVER IlX1,0'NI BTU) TOTAL:
as defined by the Cupvnino Municipal Code,Chapter 9.12,and the Health and Safety
GrJc,$mllna 25532(a)7
Cl Yes C1 No VENTILATION PAN(SINGLE RBSID)
BOILBR-COMP(3HP OR I W.000 BTU) ISSUANCE DA'rE
Will thexpplicnnt nr future huildingocenpum use cyuipmnuordevicwwhiab emit o py p � 1'1
Imzco
ank..a air nmmimmx os defined by the Ray Area Air Quality Management BOILER-COMP(OVER IIgodd BID
'U) V V' M
iatrin'!
❑Yes 0 N NEW RFSIDENTIALMECIL SQ.FT. FEB 41993
1 have mid the handful materials requirements under Chapter 6.95 or the
Culifomia I ImRh&SafetyCade,Smrions 25505,25533 and 25534. I undemand that r,
Bits,building does not currently have a mount,that it is my responsibility to notify the CITY LI- k; Uf CI11l1YV nQ
oecapam of the requirements which must be met prior to issuance of a Cenificam of (/V-J
Occupancy.
Owner,onnmhonud agent Dare TOTAL: ISSUED BYJ`4)/V7a'kJGGt
OFFICE