24567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
Y OF CUPERTINO B 1, 1 c-ELEUI'RI AL PERMITNO
APPLICATION/PERMIT PING ROJECTECBANICAI. 24567
z� 5 6 7
+UILUINCi DIVISION BUILDING 1'kOJECI'IUENI'IF'ICAITON L 4 'V1 FVC
;0jN
DINNG ADDR1iSS: SANITARY NO. APPLICATION SUBMITTAL DAM'
1 UNITq LOIN 1�Z ' /'{.�"(
ERS NAMH: PHONE 4�OMIRACI'OR'S NAME: LIC NO: NIC CONTROhN
MItC O YLf u Cit c+w 7EFECT'/ENGINEER: LIC NO: ADDRESS: ❑Y 13 R;k1trS;�t r ''I)fu�-
ONTACT: PHONE: BUILDING PERMIT INFO
QTY. LLECTRIC PERMIT FF,P,
BLDG ELECT PLUMB MECH
1 PERMIT ISSUANCE 15.0t.)
LICENSED COMAA[TOR'S DECLARATION APPLIANCES-RESIDENTIAL. LOB UESCRIPI'ION
yrz I herehyaffirm that l rnt Licensedunderpowisi.as nfCTupter9 mommencimg with
00❑ Sation 70001 of Division 3 of the Business and Professions Code,end my license is is PANELS
�U U full force and eff t. ,I
Zw Licen�Class Ia Lic.a Ca LI 4a I7l DPT0200AMPS
Qvst'i
Dole`i,-1 Contractor)( 201-I000 AMPS
z V'z ARCHITRCTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.IT.
CVC) 1 undersand my plans shall be used as public tern is.
ipY � IlcensWlimfoxional SIGNS ELECTRICAL
p,owu OWNER-BUILDER DECLARATION SPIiCIALCINCUIT/MISC. Ni
xP. 1 hereby a[fmamm
t that 1 um cxpt frothe Contractor's License Law for the sem
ul�pa, following reas .(Section]031.5,Boston.and Profession,Code:Any city.,county TEMP.METER OR POLE INSI'. ``
1.' w; which requires a permit to construct,after,improve.demolish,or mpair any sh ucare
D-:E poor to its issuance,also requires the applicant for uch Permit o file a signed statement POWF.RDEVICES
Q O that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter
d �' HTER
9(c.mmencin with Section 70010 fDivislon 3.fthe Businesaand Professions Cale
0 8`s" )° ) SWIMMING POOL ELECTRIC V I� VALUATIO
-„y Sectio 7031.5 by any afromand the permit
subjealkgedeeempt,to Anyvionalty of OUTLETS-SWITCHES-
N tralm re than five
hundred
dolt ($500mit subjects the applicant mucivil penalty of FI%TUNES
E ¢O nm ml,uownrofthedmdry,ormyem). NEW RESIDENTIAL CLECDt .FT.
Lo ❑ Lazowrk,anhcpropcny,e,myempinyeeswiawegesns ore(Ser.
compensation, STORIES TYPE CONSTRUCTION
L will dothe wons and the structure Contowbars License
ndcde Law
dos not
ply 7044,Rosiness
and Professions Cale:The C s thc='s 1 d who Lew does not apply to an owner of
propertywyees,pdsorimprovesch impa,and entsmasuchwoa Mmuched thnagh his
woe CT,thebuildi goyim improvement
earrof ompleterc,ficirthe ale.If, OCC.GROUP RES.UNITS
however,thebuildingorimprovementissold within oneyew or mprove f rtheroscof TOTAL: O
awour
Imilderr will have ac buNcn of proving that he did not build or improve for purynu of s
r sale.). TY. PLUMBING PERMIT FEE ILOOD7.ONE APN
/ ❑ Iuct he profflhe ject(Sce.70,umexclusively Nofieiars hlic)The comments to Q
nmaouct the project(Seco](154,Business and ProPossi.ns CaleO The Comracto(s
Li henul.ewdoer nee upplymowith ac ramererty whnsedpunrimproves Coram,end PERMIT ISSUANCE
whense Lunsfa such projects withacantmcmr(s)Iicrnud pursuant to the Contractors AI:I'1iR-DRAIN&VENT-WAIER(CIA) FEE SUMMARY
License Law.
❑ I wn cumpt under See. ,fl&P C for chis rtason BACK FLOW PROTECT.DEVICE DE
SANITARY YN
Owner Date DRAINS-FLOOR,NOOF,AREA.GOND. RECEIPT'*—
LA
WORKMAN COMPENSATION UBCRATION SCHOOL TAX YN
l hertby affum theJ heveacenificam ofc.num mselGinsum.rnu eenificu¢of FIXTURES-PER TRAP RCCF.IIPTp
m' Camprnsetim Immoeemacenifiev copy thereaf(Sec.38m,Lab C.)which PARK FRE Y N
covers all plo e<'e under j per 81. GAS-EA.SYSTEM-1 INC.4 OUTLETS R[CLI'T.
BOBcyN V - BUILDING DIVISION FEES
Company G pk GAS.P.A.SYSTEM-OVER 4(EA) PLANCIMCK FEE
❑ Con R*ild copy is hereby fumia I.
a Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed iflhe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200PT. ENERGY FIDE
or less)
I certify that inthe pertncomee.f,ha work farwhishthi,permit is issued,Ishall - WATER HEATER W/VEN`UELECTR
not employ any person in any m as to become subject to the Worker,' PAID
Compensatim"wsof Celif.mia. Date e0 WATER SYSTEM/TREATING
Data Receipt If
p z Applicant
z 0 NOTICE TO APPLICANT:ILafmr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
f-+ V) become subject to the Workers Compensation provisions ofthe Labor CNe.you must
ai ; forthwith comply with such provisian,orthis permit shall be deemed revoked. BUILDING PER
Pw-, A CONSTRUCTION LENDING AGENCY SEISMIC PEE
Vz I hereby affirm thin them I,.construction lending agency for the perlamence of
O the work for which this .it is lssued(Sce.3197,Civ.C.) TOTAL: FLE(]TRIC PER
0 .. Lender'sName
0 �C-J+ LenddsolanneAddbor, Ql'Y. MECHANICAL PERMIT PEE PLUMBING FEE
1 certify that I have read this application and sale that the above information ie
correct.l agree to comply with all city and county ordinances and state laws totaling in PERMIT ISSUANCE MECHANICAL FEE
F-' Vj building construction,and hereby auaoou representatives;ofthiscity toeacrup.n the
U 7 ebovcmemioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUC71ONTAX
F7 (We)agree In arm.indemnify and keep hamdess the City of Cupertino against
liabildies,judgmema,costs endo.,..which may in my way accmeagairmt said City AIR I IANDLING UNIT(TO 10,00)CFM)
in conuquence of the granting of this permit.
—4 ^J AIR I IANDLING UNH'PCOVER 10,000 CFM)
Signe.of Applicant/Comanaor Data EXI IAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam RemiptN
Will the applicant m fuart building occupant store ar handle haunlous material HEAPING UNIT(OVER 100,W0 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crdo,Section 25532(u)7
Cl Yes El No VENTILATION FAN(SINGLE RISID)
BOILER-COMP(3HP OR 100,07 BTU) ISSUANCE D
Will the oconciminrfumre building by the ay Ana Air .alit Mae. nchach nt /
District?
air conaminents as defined by the Bay Arca Air Qddhly Management BOILER-COMP(OVER 100,000 BTU) {fq pS if1
❑loin? Ir W 1V
❑Yes ❑No NEW RESI01'NTIAL MACH. 9Q,FT.
I have mad the hiscSafety
Code,
mammals requim5533 under CTlnprer understand
of the FEB 211993
if the uil Health&Sefco Cafe,Sections 25505,25333 and spersi I ity w mond Chet
wthebuildingdoesnotmentsr w ich ast he rhinitis myssuannsibllityernotify the
occupant of the requirements which run be mm prim to issuance.f a Certificate of
Occupancy. G((Y Q f CUri".hI II
Owner or uwhrrized agcm Data TOTAL: ISSUED BY.
OFFICE