26411 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "' PERMITNO.
APPLICATION/PERMIT PLUMBING-NIECHAN]CAL BUILDING DIVISION BUILDING PROJECF IDENTIFICATION
BUILDING ADDRESS: ./J a/I SANITARY NO. APPLI7D Ng SUB I'1'N.DATI?
,•moi/// • UNIT# LOT# ,(�
OWNS SNAML: HON CONTRACTOR'S NAME: LIC O: _1
P'UO'S17 O NAC CONfROLp
CHITS /HNGINEER: LIC NO: AD ES
CONrnCI': ��..�/ •tom/l7 PHONE' /J QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�rP4 VV/t{� 3 / 7.Cj/OA EO rI.U❑MR ME❑CI
`J 1 PERMR ISSUANCE
LICENSED COMRAerProSDECLARATION APPLIANCES-RESIDENTIAL � pp PPI
OCZ Ihereby affirm thatCENSEDCONITRAI an licensed TOR'isions DECL DECLARATION
9(commencing with
wOO❑ Seelim 7MO)of Division Sof the Bmines,md Prolbssions Code and by license is in PANELS /�
TUU full force and dla al UP T0200AMPS i/fix�ai� � G
License Clas Lic.p �aZ�J�[ � U-WORAREA ^^ O
yjy Dam Convector 201-1000 AMPS SQ.I'I'.IlOOR AREA S/SQ.1-7.
ZFOyZ R ITF.CTS DECLARATION OVER 1000 AMPS
O Z_n 1 understand my plans shall be used as public records.
F=�J SIGNS ELECTRICAL
QY -4 Licensed Professional
sc OWNER-BUILDFR DECLARATION SPECIAL CIRCUIT/MISC.
XOyu I hereby afr.that I em exempt from the Contractor's License Law for the -
wzr3 v following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F a O which mquims a permit m construct,alter,improve,demolish,or repatr any structuref-YM prior m its issuance.also mquims the applicant far such Permit to file a signed statement FEWER DEVICES
aa M C) that he is licensed pu stmt to the provision of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
o 9(commencing with Section 7")of Division 3 of the Business add Profusions Cade)
❑y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHCS-P TURES /37�
h Z a Section 01131.5 by any applicant for a permit subjects the applicantto a civil penalty of
t more than Eve hundred dollars 155 W). NEW RESIDEMI'IAL E CMS FT.
KC� C11,asownerofthepmpeny.ofmyemployeeswiNwagesastkirsolecompen.Uon. Q' STORIES TYPE CONSTRUCTION
Wig— will do the work,andthcswaum isnotinmndedoroffefed rat salefsecJ044,Busin�ss
and Professions Cadie T e Convenor's License law does not apply to an owner of
pmpenywhubuildsorimpmvesthemnn,andwhod«ssuchworkhim lfmthmughhis O(C-C.GROUP RES.UNITS
on employees,provided Nalach improvements are not intendedoroffered formle.If,
however,the building or improvement is sold within one year of completion,the owner- TO I AL: 5
builder will have the burden of proving that he did not build or improve for purpose of r
sale'). QTY. PLUMBING PERMIT FEE Il. )U ZONE APN
[3 Las ownerofthe property,not nexclusivelycormenting with Bemused contmemrato
onawet the project(Sce.9044,Business and Professions�p�) �asCr�rnmg4
License Law d«snot apply man Ownemfproperry whobuilJs¢imprs6iheieoA.ebd rE tMI ISSI�q I
whocomracts formeh projects with a contracher(s)licensed par tmme Cnmmemrk
License Law. , ALTER,DRiAIN lii
Nf-WATER(EA) FEE SUMMARY
❑ 1amexceptundegee d se/ OUTSIDE FEESC DEVICE
SANITARY YN
Owner Dam -FLOOR,ROOF, REA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATIOE)JjTE SCHOOLTAX Y N
❑ Ihertby affirm that ihave ocenificum of consenus�. If-insum,mauni ncam ES ER P: RECHIPFk
Workere Compenmtioulmoranceora cenificdcopyloom ..38W.Lab C.)w icM1 PARK FEF: Y N
Prs all cm IW2'' t I. - .I INC.4 OUTLETS -W. RECISION
olicy# �G HULLOING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ Cenifedcopyis erebyfamisbed.
Cenificd copy is filed with the city inspection division. GREASEIINDUSTRL WASTE I CEPTOR GRADING FUR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Ihi,,ecion bend not twenarplerd lithe permit is Intone hundred dollars($100) SEWER-SANITARY-STO EA.2001-7. ENERGY fTH
or ler")
I certify that in doe Pernerambe of Ne work for whichthis Permit isieem Ishall WATER HEATER WN /ELECTR
not employ any person m y r n m become subj�u PAID
Compensation laws of a beer o t WATER SYSTEMIM TING Dam Receipt#
rI, Apphcanl NEW RESIDENTIA PLMIL SQ.FT. TOTAL:
NOTICETOAP..he Wo :If,C, 'nkig i.'iamnaof of Exemption,you should
F"' - hu:omeh comply with
the Worker'ssidium . un odsonsof the Labor Code,you must
a > forthwith comply wirM1 such provisions or this permitrahnll he deemed invoked. BUILDING II3E
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
:D z I hcrebyaffirm and them isocommand.lendingagency for the perfontnnce of TOTAL: ELECTRIC ITE
U Q the work for which this permit is issued(Sec.3091,Civ.CJ
fAp Lender's Name TY. MECHANICAL PERMIT FEE
FEE
Lenders Address Q
U I certify that 1 have read this application and stem that the above information is MECHANICAL ITE
>^ correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
h-' building commuction,and hereby authofire representatives ofthiaciry to enter upon the CONSTRUCTIONTAX
U z above mentioned property for inspection purposes. _ ALTER OR ADD TO MECH.
(We)ugme nt rove,indemnify and k«p May in
the City of Cupcnst s against
Iiabilities.juJgmems,coats mdup rax 1 hich may in any way accme against said City AIR HANDLING UNIT(TO 10,MCFM)
innmseyue a of th br4r, is Inuit.
r AIR I IANDLING UNIT(OVER 10,W CF
16
Signature plicant/Contou' lla EXHAUST HOOD(W/DUCI) PAID
HAZARD US ATERIALS DISCLOSURE HEATING UNIT(TO 100.0008 Dam Receipt al
Will theapplicant or fitimbeIttTildia,occupant snort or handle hmsrdom eamerial HEATING UNIT(OVER IW, BTU) 'TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)'! VENTILATION FAN(SING sRESID)
11 Yes 11 No
�DATE11
Wll dre applicant or future building occupant use equipment or devices which emit BOILER-COME GHP 1ISSUANCP.W,g10 BTU) W AT 0
aradons air con aminates as defined by the Bay Area Air Quality Management BOILER-COMP(0/_R 100.000 BTU)
J:au;eR 11MAY 27 1994
❑Yea No NEW RESID AL MECII. gQ.Ff.
1 have read the hmurdens materials requirements under Chapter 6.95 of the
Califomia[Icahn&Safety Code,Sectiam,25505,25533and 25534.I understand that ICITY Ur w1v-1 If. 0
if the building does not currently have a tenant.that it is my responsibility,to notify the
occupant of the requireements which must be mat prior to issuance of a Cent E
cale o!
Occupancy.
Owner m authotieed.,at Date TOTAL: ISSUED BY:
OFFIC -