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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
APPLICATION/PERMIT PLUMBING - MECHANICAL
RINGADDH DIVI510 HUH.DING PRO d- CTIDENTIFICATION
PERMIT NO.
24946
BUILDING ADDHO p II {,fy
' -* /L -O41-( KQ� /I �. 'ONI'I'p LO'I'N
Nlt'ARY NO.
APPP/LIIIC,VUONSUUBMITI'ALDATF.
OWNBRSN MIs:V PHONE?: r
?> FF (aL RD YS KW OK 2SJ _ I /be
CONTRA O :S NAM LIC O:
NIC
CON'1'ROLp
5
ARCHITECGENGER: INELIC NO:
C -21,(N VoN
ADDRESS:
CON'IACI': PHONE:
�L AD rS /Ct D /C 2sr -Irl $B
/r
-
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
ELT PLUNJP MECII
PEWITISSUANCE
LICENSED CONTRACTORS DECLARAt'ION
Ihcreby Chapter and (commencing with
APPLIANCRS-RESIDHNI'IAL
PANELS
oftmthaU 3 ofth Business and Professions
forceandof Division Jof the Business anJ ProPowions Glue, and my license is in
full and effect.
Liocasec
Licenu Class Lic.p
UP T02W PS
Data Cnmwctor
201 - Ram S
ARCHH'ECTS DECLARATION
I understand my plans shall he used as public records.
OVER Ran) 5
SQ. Ff. FLO(R AREA
$/S I'.
2
Jr
SIG ICAL
�� 03
6
Licensed Professional
OWNER-BUILDER,,forDECLARATION
!VN -61 R 4NISC.
hereby rat 1 am exempt from the Contractor's License Law for t
n. tion sion&Co
Code: Any city or Crani
following reason. arenna. armaS,Busim, improve
which requires. permit re rnnwct,
which improve, detwliab, rr repair any mune
MP. ;TIiR OR POLE INST."111
��
ppIx store
priore its i,emadp,.art
lh<upplicanrtthe chpetrnie,
POWER DEVICES
41
that bat Is Iloeaanl pnwunt to the) of Doors of the Cenrmean'a License Law (C
to the Utmst, La
9(eommencing with Section 9(NIG)ul'Ulvision3 ol'Ihe Busines and Professlonx CrafaL
or that he is exempt herefrom and the basis for the alleged exemption. Any ul�
Section 703 Lapplicant for. by any applicfore permit subjects the applicanTto. civi l��l�/,
L4
SWIMMING POOL ELECTRIC _
VALUATION
1' "S TCtIES I ES O '
act mom Than five hundred dollars ($500).
CII, usownerofthe properly,ormyemploymawim wages as lhcirsolecn m
will tlnthe,ims, and or
Cereonceris
1 Lf SQ. E.
STORIEST ONS"fRUCfION
and Professions Code: The Contrecmrs License Luw does oat apply to an owner of
e: The Limn iev doesa,,, up, y to an owner
proPeny who builds or improves thereon, and who does such work himwif onhmp
wncmphyces,proviricd Natsuch improvemenuumnotimm�riedoroReredfor NCM
OCC. GROUP RES. UNITS
T
however, the buildingor improvement is sold within one year ofcompletion, the owner-
builder, H have the burden of proving that he did not build or improve for pagmsc of
QTY. PLUMBING PERMIT' FEE
seta..
fret rhe propcny,amexdusivelycnmmcting with lic<nwdconwnon to
FLOOD ZONE APN
c mems the
enproject (Sec. ]044, Business and Professions Cove:) The Conttucter's
L first l.uwdoes not apply to un owner ofproperty whobuilds or ireproveathemon,and
PERMIT ISSUANCE
contnmts for such projects with a contractors) licensed pursuant to the Contractor's
License law.
ALTER-DRAIN&VENT-WATER(EiG
FEE SUMMARY
❑ I am exempt under Sa. , B & I' C for this reaun
BACK FLOW PROTECT. DEVICE
f. IDE
SANITARY Y —N—
RECEIPT p
Owner Data
WORKMAN COettiicam ofIONUECLAlf-inaON
❑ Ihertby affirm that) have acenilicme of conunno self -insure, ora anificme of
Wduken'Compenwtion inuwnce orucenificd copy thereof (Sec. 3800, Lab C.)which
GRAINS - FLOOR, ROUP, AREA, COND.
SCHOOL'I'A% Y_N_
RECEII'I'p
FlXTURE.S - PER TRAP !''�p�
/�G•
PARK H.P. Y N
GAS - EA. SYSTEM -1 INC. 4 OUTI.US
_ --
covers all emplmyce's under Nis permit.
Policy#
RECEIPT' p
B r GDIVISION Fla
PLANCHEC f'
Company
GAS - EA. SYSTEM-OVHR :M.., \'
( \ ��,\:'-'
ElCertifledcopylsherebyfumished.
❑ Certified copy is filed with the city inspection division.
GRFASF�INDU"Ir, '- ltd \ y
GRADI F
CERTIFICATE OIC EXEMPHON FROM WORKERS'
COMPENSATION INSURANCE
(Ihissedionneed not be completed ifhe permit is forone hundred dollars($10)
or less.)
CREAM' NZ- Sx
s t U✓
-\l
OCH
I canny that in the performance ofthe work for which this permit is iwuM, l shall
WATER HEA'. I., IrNT@•.LE= Cl it --
not employ any person in any m:mner so m to become subject to the Workers
-
PAID
Compensation Luwsm Cakfarri Date
WATF.RSYSTEMITREAt'ING
Data eceiplp
NOTICE TO APPLICANT. If. after making this CcAficam of Exemption, you should
NEW REST DENTIAL PLMR. SQ, FT.
TAI:
become subject to the Workers Compcturawn provision of the 1s1hor Code, you ..at
forthwith comply widsuch provisions or this fermi t shall be deemed revoked.
-
BUILDI it
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affimvhat there is a mnstmction lending agency teethe performance id
the work for which this .it is issued (Sec. 3097. Ci, Q)
Lenders Name
TOT 1..
ELECTRIC FEE cc
Lender',, Address -
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
I certify that 1 have read this application and state that the above information is
correct. l agree to comply with all City and county ordinancesandsmm laws reliang to
PERMITISSUANCG
building construction, and hereby vuthonea represernurlves ofthis city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MFCH.
CONSTRUCTION TAX
(We) agree In save, indem Lily and keep harmless Ne City of Capetian ugmirsl
linhiliries'vdgmcros,cnsb andcxpen.+es whichmay inuny way nccryyy555egamass icily
in corn aacenj.Me. ing of is permit. /� � \
`(�7 /
A HANDLING UNIT (T010,W0 CPM)
DLING UNIT (OVER 10,000 CTM)
numroof Applicunt/Comructor Dr,
EXHAUSTHOOD(W/DUCT)
PAID
HEA ONO UNIT(TO IM." BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt#
Will theuppliaut or forme building acupmtsms, or handle harerdoua material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 10i BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
Code, Section 25512(x)'1
❑
11 Y. EI Nn
Will theopplicani orfuwrebuilJing occupam uxequipmemardeviceswhich emit
�Dieands , air contaminants u defend by the Hay Arca Air Quality Management
❑ Yes ❑ No
fiS}IANCE
1 1 DATEVV
MAY 1 + 1994
100,000ROLLER-COMP(3HP OR I00 HIM)
BOILER -COMP (OVER 100.0 0 BTU)
NEW RESIDENTIAL MRCI I. SQ. FT.
1 have read the Incurious ma¢rials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.2.5533 and 25534. 1 understand that
V Ur CUrthlwU
if the hot ineg docs not currently have a ¢rant, phot it is my resgntsibility m net fy the
cupunt of the requirements which most be met ,in, a issuance of a Cv, ifiale of
sm
Occupancy.
ISSUED BY:
Owner or authorized ,at Data
T
OFFICE