26293 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUII"DIN "" RICAI PERMIT NO.
APPLICATION/FERMI'( PING PROJECT
- T[DEN TICAL 2 6 2 9 3
BUILDING DIVISION BUILDING PR03K(YT IDENTIFICATION v J
BUIL]DI�NG ADDRI3S: SANITARY NO. APPLICATION SUBMI'TPALgDa I,
AT
W/✓I� UNIT# LOT: /✓1i/QQ'k%{
OWIgiN O PITON C fHAC'IbH'S NAME: LICNO, NIC III CONTHOLp i
• ARCIIIITECDENGINEER: LIC NO: ADDRESS: ❑
TACT'' PD NE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
O � 7o',LJ DG ELECT PLUMB MECH
T 3 -/;! � PERMIT ISSUANCE El 0
LICENSED CONI'RACTOR'SDECLARATION APPLIANCES-RESIDENTAL Jpg
UFSCRIIION
OKZ lherebyafnnlicenseduE 'Chap (commencing with
1100 Smtim700 )ofDivisio3oftheDusineswdroft%ionsCWe,wdmylicnisin PANELS /a`LA
full force and effect.
<-ZW Usines Claes Lip.# UPTO200AMPS
h a Il DCte Conpacror 201-IOW AMPS
'� SQ.FT.FLOOR AREA $/SQ.FT.
Z FONZ ARhalITIiLTSDECLARATION OVER 1000 AMPS
O Z_❑ 1 undersand my plans shall:used as public records.
r` W SIGNS ELECTRICAL
KK , I,iernucJ Note sxional
90'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XC'u I hereby affirm that 1 Cm exempt from IM1e Compactors License Law for the
W 3 W y following reason.(Section 7031.5,Business and Professions Code:Any city or wanly TEMP.M=R OR POLE INST.
which requires u permit to conceit,alter,improve,demolish,or repair any structure
!j Y� prior In he issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
�a a
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
Ca9 SWIMMING POOL ELECTRIC VALUATIOy-ftaw
(commencing with Section 7000)of Division J ofNe Business arM Rofeaaions Cade) Com.
orthm he is exemptherefrom and IM1e basis forthe alleged uet iron.Any violation of
K 7 Q y any applicant Permit subjects applicant pen y OUTLETS-SWITCHES-FIXTURES
} notmn7W 1.5 by I par,($ tsub' t thus noecivil alt of '/ /
nt mineetheM dollars($5W). V
� NEW RESIDENTIAL R _SQ.FT. TYPE CONS'fHUCT10N
❑ oche wrk.andeproperty,armycmpinyexi or oferadl for Weirsolc c0LBusiuw.
y3. will Jotbewons Code:shunupaistorimendeseofwdoes of apply 7o em Business
and enywhions Code:The Contractors ndwho Law dais or apply if w owner is
pmpcnyw:builJxorimproves lhcrcon.anJwhoJcesvucM1wnrkhimulfonhrough M, .GRG II' RES.UNI IS
emr.the
building
uildlhae such improvemwitcoin canned oroffered n.thea e. r- I I4.r
however.millhavlthe burden of provingermin hathsaid within oneyear or improve frpurpose of TOTAL:
builder will have the burden of proving that:did not build m improve for purpose of
sole.). QTY. PLUMBI PERMQAII=
❑ Lasownemdthcpopeny,um explusivdy wntraming with licensed commemrslo LUODZ E MIN
wnspuct the project(Sec.7041,Business Dad Professions Code:)The Contractor's
License Lawdoesnot apply low ownero(property who builds or and PERMIT ISSUANCE
whocontmets forsuch projects with a contractor(s)licensed purauant to the Compactors EA ALTER-DRAIN&VENT-WATER
License Low. f > FEE SUMMARY
❑ 1 ane cxpmpl under Sea .D&P C for this reason OU'I'SIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-FLUOR,ROOF,AREA.GOND. RECF:IPI#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihcreby affirm that l have acenificale ofconsent toselbinsum,ora cenificate of FIXTURES-PER TRAP RECEI #
�Workera'Compwaniam Insurance or acertified copy lherad(Sec.3800,Luh C.)which PARK FRE Y N
n all sem,eCs uad,this permit. RE PT#
Policy# GAS EA.SYSTEM-1 INC.d OUTLETS BUILDING DI IS . 'S I III
Company GAS-EA.SYSTEM-OVER 4(tis) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is filed with IM1e city inspection division. GREASEUNDUSTRLWAS'1'LINTERCEPI'OR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sectinnneed nothe complmW Bum,permit is fnrone hundred dollars SIM) SEWER-SANITARY-STORM F.A.20017T. ENERGY FEE
odes")
(certify chat in Ne P<rformance of ehe work for which this permit ixissuM,lshell WATER HEATER W/VENT/ELECR
nm employ any person in any ntwner so as in become subject to the Whrk<ri PAID
Compensation Lawsof Califomis. Date WATER SYSTEM/TREATING Date Receipt#
O 2 Applicant
Z 0 NOTICE TO APPLICANT:if,after madding this Certificate of Exemption,you should NEW RESIDENTIAL PLM Is, SQ,FT. TOTAL
f'^ y become subject to lip Workers Compenaauor on provisions of the LabCode,You must
a >- forthwith comply with such Provisions of this permit shall:dcemed revoked. [SB[SM]C
LDING FEE
Q CONSTRUCTION LENDING AGENCY TP
Z Ihcreby affirm Net Nepa is aconswction lending agency for the performerpe of TOTAL: CTRIC IEE
U O the work for which this gamut is issued(Sec.3097,Civ.C.)Lenders Name MBING FEELenders Address QTY. MECHAMCALPERMIT FEEU I sanity th n 1 have readthis application and state that the above information is HANICAL FEF,Lel correct.l agree to comply with all city and county mdinwca and sate laws palating to PERMIT ISSUANCEbuilding conswnion.and hereby amhoire repreaetsuves ofthis city to enter upon the STRUCTION X
U Z above-mentioned r,my for inspection plopres. ALTER OR ADD TO MECH.
(We)agree to anvp,inden ni fy and keep harmless the City of Cupertino ngitilin
liuhilitics,' mems,costsand cxpcnsea whi mayim any wayaarueagnin" id Cit A IR I IANDIJ NO UNIT(TO I LI 00 CFM)
ins sequence he grwein8 of this
AIR BANDUNG UNIT(OVER 10,000 CFM)
Signamreo cum ontracor Dal EXf1AUSTDOOD(W/DUCD PAID
I{AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Recei
Will the applicant or future building occupant sore or handle boundless material I ICATING UNIT(OVER 100,000 BTU) TUI AU
as defined by the Cupertino Municipal Code,Chapter 9.12,solids,Ihealth and Safety
Colic,Section 25532(a)7 VENTILATION FAN(SINGLE RFSID)
❑Ycs ❑No
ISSUANCE DATE
Will the applicamorfotum building occupanlma equipmentordeviecawhichemit BOILER-COMP(3HP OR 10[L"BTU) P A V D
hnntrdous air comamlnams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1W."BTU)
Diss cB
❑yes ❑No NEW RESIDENTIAL MECH, SQ.FT. yl APR 2 5 1994
I have read the hazardous materials requirements under Chapter 6.95 of the
CalU mlaHealth&Safety Code.Sections 25505,25533 and 25534. 1understand that C�IY
if the building Jots not currently have a icnam,that it is my responsibility to notify the V tit 1„1urtklllVu
Ocupant of the requirements which must himet prior to isswnm of a Certificate of
ccupancy.
Owner or authorised agent Date '101'AL: ISSUED BY
OFFIC