24907 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOB B,IJNG-hi,kc'1'RICAL PERMrr NO,
APPLICATION/PERMIT PLUMBING-MF.CIIANICAL n ^ (J0
BUILDING DIVISION BUILDING PRO.BICI'IDRN1T
' FICA2 LI J'TION I
BUILDING ADDRESS: (/(I 1kx� s1!a rfI WL SANITARY NO. APPLICATIONSSIUBMITTAL DATE
UNI'1'p LOT It
r, O g / 0 RS MEG:N
PHONE CONTRAKS NAME:
796-1915" Jc1� 0� V/
.1 70 NIC CONTROLEf
ARC IiC/kIES 1:1_ AX Ii Wbso Qusel ave 6G4r,+
CON'1'AcT: PHONE: BUILDING PERMIT IN]0
QTY, ELECTRIC PERMIT FEE
�OfYt VJI BLDG ELECT PLUMB MECH
q0T 77--)IS PERMIT ISSUANCE. ❑ ❑ ❑
LICENSED CONTRACTOR'S anderpmviionsof RATION APPLIANCES-RESIDIiNTIAL +r++ I+v;
py.Z Ihereby affirLICENaEDCONTRACTOR'S DECLChepmr9(commencingwith ter:-{`S:,
'I,E[ fallSection
rce and OfDivision 30f the Business and Professions Coda and my license is in PANELS
��U fall avdeffem.
6Fjy) Licenm Clav Lic.p UP T0200 AMPS
y 6 y Date Contrrwmr 201-1000 AMPS
Z Oma ARCHITECTS DECLARATION OVER 10(10 AMPS SQ.FT.FLOOR AREA SQ.FT.
OZ I+mderstand my plans shall be usedav publicrecords.
241 SIGNS ELECTRICAL
Liccnsel l'rofessionml
OWNER-BUILDER DECLARATION ON SPECIAL CIRCUIT/MISC.
ad la U I hereby affirm that 1 am exempt from the Commdore License Law for the
LW.LLOQ fnllowingreus.r.(Section]031.5,liusineasand Professions Code:Any city orendnly TEMP.MEfERORPOLEINS'I'.
.]] which requires a Permit to conswet,utter,improve,demolish,or repair any someone
C QE prior m its issuance,also requires the applicant for such pe Ip geedy�en nt ER Cr
yl_ p that he is licensed pursuant to Ne provisions of the Comm dh 1lf�lce�sL Ce (q+e er
o-,.Rs 9(commencing with Section]Ol10BOT Division 3 of the Business and Pro& i6ist MMI G LELECTRIC VALUATION
y)_y m that he is exempttherefrom and the basis for the alleged pi y O CHES-FIXTURES
C Z Q Section 7031.5 by any applicant for a peonir Subjects thea f t ri✓jl oo rIt
t more than Eve hundred dollars($50)). _MkNTIAL ELECfR _SQ.FT.
4m n❑ 1,vaownemf\he property,ormyemployeeswithwagesastppiSsplptpmpensmi STORIES 'I'VI'Ii CONSTRUCTION
willdo the work,and the structure is not intended oroffered for 17044 B i
and Pa+foesinnx Code:The Comromnr's Liame LJtp does not upPly 1.an owner o
properly who huildsor improves thereon,and whodoes such workhimselfoehmugh Its OCC.GROUP RES.UNITS
n employees,provided thotsuch imp..v,orma are nm imandedmeffered I'o..SS.IL
however,the building or improvement in sold wilhin one yearofcompletion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
Sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Laswnerdeci(See ofthe 701. usimeav and Professionng s
withtoContractor's
nava the project apply
]1A4,Business and Professions Codc:7 The thereon,and �a
IS
whoccLicenselawdcersuch pplytoanowneminaricny whosed pursuant
Conti mond PERMIT ISSUANCE.
whemnoaw.forsuch projecu witharnmracmr(s)Iicensed pursuannothe Contractors ALTER-DRAIN&VIJJT-WATER LA �^'
License Law. (' ) FEE SUMMARY
❑ 1 and exempt utuler Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIffr,MEN
SANITARY YN
Owner Date RECEIVE p
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPIiNSAI'ION DECLARATION SCHOOLTAX Y N
❑ Iherchy off lint thatlhavencenifc:nc of cnneenuo self-insure,ora certilicatc of PIXTl1RE5-PER"TRAP RECHIPTra
Workers'Compensation Insurance ora cenifal copy lhereof(See.3800,Lab C.)which PARK FRE Y_N
asrcrx all muAy�s.updy Wa py�frY3u� �/ GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPI
Pn " 11 BUILDING DIVISION
IRPS
GAS-EA.SYSTEM-OVER4([iA) PLANCHECK FEE
enified copy I,hereby famished.
Certified copy is filed wiNthe city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEM1'LIION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thissectionneednotbecomplemd ifthepenmir isforonehundmddollam(SID) SEWER-SANITARY-STORM IA.2001T. ENERGY FEE
orless.)
I really that in the performance Of the work for which thisperit is issued,I shall WATER HEATER W/VEN'I'/ELF M'R
not employ any Former in any manner so as to became subject 10 the Workers PAID
Cnmpcnsulinulawxof Califomia. Date WATER SYSTEM/TRHAfING Data Receipt#
Z7-+ Applicant
0 NOTICE 1'0 APPLICANT:ILuflermaking this Ceaifcatcof Exemption,you should NLWRES EN,Ad.PCMB. SQ.FT. TOTAI.:
(•-' V] become subject to the Workers Compensation provisions Of the Labor Code,you most
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z Ihereby afford that there is a construction lending agency for the performance of
V O the work for which this Permit is issued(Sec.3097.Civ.C.) AL: ELECTRIC FEE
Lender's Name PLUMBING FEE
0 U Lerdcds Address QTY. MECHANICAL PERMIT PEE
1 certify that I have read this application and slate that the above information is
correct lugree mcnmply with all city mnJ county mdinmces ants'state laws relating to PERMIT ISSUANCE MIiC11ANICAL FEF.
barrio,conso efi m and hereby ualhodr,represcoutu,vs of lhie city to cowman the CONST'RUCf10N TAX
V y above-mentioned progeny for lnspecomn purposes. ALTERORADD'TOMHCH.
G (We)agoo m save,Indemnity eM keep pointless the Chy of Cupertlnn nguhtNt
liubdities,judgmcnls,costs and expcmcs which may in way accrue against said City AIR HANDLING UNIT(TO 10.000CFM)
I. mance of theBmntinB of this .27 2
9J AIR HANDLING UNIT(OVER 10.000 CFM)
pmaDam XIAUSTHOOD(W/DUC) PAIDS oS
MATERIALS DISCLOSURE HEATING UNIT(TO 1009,000 B'HH Dole Racipl p
Will ocaramfuwrebuildiagoom,ant smarm aadlehurrobusamedil HEATING UNIT(OVER 100,000 BTU) TAC:
as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safely
Cube,Section 25532(a)]
Cl Yes ❑No VENTILATION FAN(SINGLE RISID)
ISSUANCE DATE
WIII Nenppllcanmrfumrd bvildingncrupdmureeyalPmenmrdeviaswhlch emit BOILER-COMP(311P OR 100,003 BTU)
huxurdnus air contaminants ns Jefided by the Bay Arca Air Quality Management HOILER.COMP(OVER 100,000 BTU) 1Rr A I+l
Diwrim] Y' f4 Ls'
11 Yes 0 N NEW RESIDENTIAL MECIi. SQ.FT.
I have mad the hazardousde.materials reyaitementa under Chapter understand
of the MAR 29 1993
California a mail
eatery Coda Sections 15505,25533 ement and 25534.1 ter 6.9and Nut
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which most be and prim 1s'issuance of a Certificate of /s"�'
Occupancy. V V
Owner or amM1orized agent Date TOTAL: ISSUE BY:
OFFICE