24894 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CrrY OF CUPERTrnO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL -
RUILDIN(,DIVINIGN BUILDING PROfF,Cq'IDEN'FIFICA'TION 24 894
BUILDING ADUNFSS: x n SANITARY NO, APPLICATIONSUBMIFFALDATE
4UNIT'# LOT It
OWNERS NAME?: -Q ,� PHONE: CONTNACT�ORg NAME: �e� LI _ NIC, CONTROL#
CI ITTE57HNGINEER: LIC NO: ADDRESS: /�J'fTe/r ''�.yy 3� ❑ OIs
I NR
CONTACT:
I . PHONP'
ELECTRIC PERMIT FEE BUILDING PERMITINFOC� �wlIC �yr /AMQTY. BLDG F11Cf PLUMB
M❑ECHC -SSS `
PLRMI'1'ISSUANCI? X
LICEIdSEDCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hcmb firm Nat lam llcenacdander s'obefCheter hmoundacin with JOB DFSCRIM]ON
❑00 Ye prow p .i
4100 Sectioncar rfDivisimn]-the Business and Prnfcnainns Code and myli«nsc is in pgN1i1S
Fq�L� full force and elf l
<< License Class ---
most UPT0200AMPS
wQy Datc Commmm 201-1000 AMPS
ZONz ARCIIITECTSDECLARATI OVER Ifkq AMPS SQ.FT.FLOOR AREA SISQ.FT.
O amu,- Koen,nd my pima shall be used as public records.
SIGNS ELECTRICAL
W �,'4j I.i«mud Professional ■ �® I�
c'CC66 OWNER-BUILDER DECLARATION SPECIAL CIRCUMIMISC ■f_
yX0 1 hereby affirm that I am exempt from the Commcmr's License Law for the
W34a,
on following aa,m.(Section 7031.5,Business and Professions Code:Any city o coum TEMP.all OR POLE INST,
C ON J which requires u permit m construct,alta,impmve.demolish,nr rtpoir any amcturc
b Fly
f1Y7 prior to its ismande,also requires the applicant for such permit file aligned statement POWER DEVICES
Rod he is licensed pursuant o the provisions ofthe Comracmr's License Law(Chapter
dWo f4 9(rnonsuming with Semen7000)of Division3ofthm lluslnessind Profession,Code) SWIMMING POOI,RLECTRIC TION
IS
tn�m or that he is exempttherefrom and the basis for the alleged exemption.Any violation of OUI'f.l-I.S-SWITCIIES-FIXIVRFS -'
Laza Section 7031.5 by snyappfcam fora permit subjectstheapplicannma civil prnahyof
� G not more than rive hundred Jolla,(550(1). NEW RESIDENTIAL ELECTR _SQ.PT.
tY m ❑ l,asowneroftheproperty,ormyemployeeswithwagesasibeirsoleeompensation, STORIES TYPECONSTRUCTION
y will do the work,and lhestructure is not ntendedoroffercd for sale(See,7044.Puniness
and Professions Code:The Contractors License Lw does not apply to an owner of
propenywhobuildsorimpmvesthercon,andwhmd«asuch work hineselfon rmil is
employees,provided that such lmprovemenuanot intendedoroffered forsale.If, OCC.GROUP RfS.UNITS
however, rc
ever,the builJingor improvement is sold within one year ofcompletim,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for pur smu of
tole.).
C1 1.m owncrofthe property,amexclusively contracting with licensed contractors to QTY' PLUMBING PERMIT FEE FLOOD ZONii APN
Lmswct the project(Sec.7044,Business and Profexvions Code:)The Contractors
icense Luwdoesnotapply to anownerofpropeny whomildsoe improves thereon,and PERMIT ISSUANCE:
whocontracts f«such projects with acnntrncmr(s)licensed pursuant o the Commerce's ALTER (FA)
License Law. ITE SUMMARY
❑ 1 oat exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE IIT ID 10iF.S
SANITARY YN
Owner Dam RECEIPI'p
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ Ibercbyaffimthmlhaveocertificamofconunnoof(Sis.3900. bc,)atioh FIXTURES-PER"TRAP RECF.IPI'p
Workers'Comlrcnmtinn lnvuran«ornc«tilted Dopy thereof(Sec.9N00,Lab Cd which PARK FEE Y N
Policy#1 employe adcrO gryt.y Sb� RDIVISI'#
#a�CC '�YY��--VV GAS-IiA.SYSTEM-I INC.40UTLETS BUILDING DIVISION FES
Compact GAS.EA.SYSTEM-OVER 4(IA) PIANCIIECK FEE
❑ Qenified copy is hereby(omitted.
Cenifird copy is filed with mr,ity in,ods,mn dwieimn. GREASIVINDUSIR1.WASTE INTHRCEPI'OR GRADING FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP 5011-S FEE
COMPENSATION INSURANCE
(Thissectinn need not he completed iftheIeenit is forma,hundred dollars 1$100) SEWER-SANITARY-STORM PA.20017, ENERGY FET?
or less.)
I ednif dnt in the perforrrmncc.f,h,work for which this Permit is issued,].hall WATER HEATER W/VENT/P.LECfR
not employ any person in any manner so as to become subject to the Workers' PAID
Conrpensatlonl.owsof Calilitmia. Date WATI7R SYSTEMITRFATING Dam Receipt#
licarm
O O NOTICE TO APPLICANT:If,afmr making 0 Ccnificateof Exem li n
z i ris rC ,ymuu mind NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
bechwithc subjecttothe Work era Compensation prom,thalof,eLahr Cvoked.umust
forthwith comply with such provisions or this permit shall be Deemed revoked. BUILDING FF.F.
C [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I I hereby affirm that hem is a construction lending agency for the perform;mce of
U Q the work for which this pemit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U
lumdc,',Nmnc
Cmlender'fs Address QTY..(r MP:CIIANICAL PERM IT FEEPLUMBING FEE
1 certify that 1 have mad Nis application and sine ncet an above information m MECHANICAL FEE
mates.]agree to comply with all city and county ordinances end site lows rtlmingm PERMIT ISSUANCE
D,J building construction,and hereby suthnriu re,nmemmiviceof Nis city m,merupm the
U Z ubme-mentlonul property for nse,ctlon puryout. ALTER OR ADDTO MECII. CONSTRUCT ION TAX
(We)agree to save,indemnify and keep hamlets the City of Cupertino against
Imhoditiet,juJgmems,cost,and.,.a which may in any wayside rueagainstmid City AIR I IANDLING UNIT CFO 10,000 CFM)
in consequence of the granting of this pcmit.
AIR HANDLING UN I T(OVER 10.000 CFM)
Sig erre of ApplicanVComr«err arc EXHAUST FOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING(INIT CIO 1 W."BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNII'(OVER 10(l,gN18'1'U) '1"OTAI
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cwle,Section 23532(a)?
13 Ycs 13 Na VENTILATION FAN(SINGLE RISID)
BOILER-COMP(31 IP OR 100,000 BTU) 1SS kVCDDA
Will the uconta contaminants
s building«cupenmu Area it nrdevicesanageme it Yr FN\ 1
hnaallous air mnmminants as defined by the Bey Area Air Quality Management BOILER IW,IXIO BTU)
District, MAR 24 1993
❑Yes ❑No NEW NIiSIDENI'IAL MECIi. SQ.FT.
1 have read the hezerdous materials requirements under Chapter 6.95 of he
California lleaith&Safety Code,Sections 25505,25533 and 25534. Iunderstandthm `CIII V� VUI'CnluvV
if the building docsamtcmra whaveatt Is, that6 is my resp onsibilityid enotifythe
«upam of the requirements which must be mu prior to issuance of a Cenllirum of --�
Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE