26412 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Q CITY OF C,UPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION AP PLICATION/PERMIT PLUMBING-MF,CHANICAL nII I n
=BUILDING PROJECT IDEN'PIFIC_ATION 6412
-- - G
BUILDING ADDRRE]SS�: SANITARY NO. APPLICATION UBMITT DTE
UNIT# LOT# �1 1
OWNF NAME: PHON- `1&'
ONT R'SN ME: I. O: ✓✓✓ `
NIC CON,R.,Jr
•ARCHITECT/ENGINEER: / LIC NO: ADDRP.SSy ❑
CONTACT: PHONE: (., s
�.��-����'$,J !.� (/ QTY. ELECTRIC PBRMIT� - FEE - - BUILDING PERMIT INFO
qr V s//l.C� 3 ( �' /��� PERMIT ISSUANCE �Qf# ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL 'JOB DESCRI ION
aCz thereby vfllr vision that I am licensedinssand kionnimas Cter9ndany Inverse with � ��
00 Section]f100)of Division3of the Business and lsrofessrons Code,and my license is in PANELS
YY11 fu 11 force and if
Fz license Clas Lar.#—��{� >y5— UP TO 2(MI AMPS ,'g,� n
mQy Uam onTSDCL�4R 201 OVER
101 AMPS (/'K
zc)-P� A ITECTS DE ARA I OVER IOW AMPS .FT.FLOOR AREA $/SQ.
CZ-0
I understand my plans shall be used as public records.
2m W SIGNS ELECTRICAL
1� Licensed Prohasional i I
�� a OWNER-0UILOERDECLARATION SPECIAL CIRCUIT/MISC. g V
O W U I hereby affirm that 1 am exempt from the ConionsCo License Law for the r
W 3 W vi following reason.(Section constrict,
Business and Professions Code:Any city shirunty TEMP.METBR OR POLE INST.
which requires a permit m constrvet,niter,improve,demolish,or repair any suucmra ,r�r
�Nr7 priormitsi,romee,�lsorequircstheapplicantfnrsuchpemi0oflensignedstatemem POWERDEVICES J
W QOO that he is licensed pursuanuo the provisions of the Commune's License Law(Chapter
Wyp R' 9(commencing with Section 900)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECT C VA TION
iW N orthathe isexemp ourrefnma,hd thebae ficathe allegelsocantion.Any violation of OIITLF.TS-SWITCHE FIXTIIRP.$
Q
S' no
by any applicantforapermitsubjectsme iredleanuo a civil penalty of /3�/�• ��
not more than rive hundreddollars($500). A E . CL.J/
w ❑ I,asowneroflheproperty,ormNEW RF.SIDF,NTILECTR
yemployxswithwagesmtheirsulecomMnsation, 5Q FT. STORIES TYPECONSTRUCTION
d will do thewark,end thestfucmie lsnotintersholOofferWfarsale(Sac A144,Business /
and Professions Cade:The Contractor's License Law does not apply to an owner of
Property whobuildsorimporestherson,and whodces such workhimselforthroughhis OCC.GROUP UR-F.S�UN11T�5
miremployeas,provided that such improvementeare not intended oroffered forsale.If,
how,ver,the building orimprovement is sold within one yeerofcompletion,the owner- .TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
a)
[1I,as ownerofthe property,am exclusivelycomecting with licensed carmacm t QTY' ]PLUMBING PERMIT. _ .,i.PEB-*i LOOD ONE APN
construct the project(See.7044,Business and Professions Cade:)The Contractor's
License Lewdaes not apply to an ownerofpropertywhobuildsorimprovIns thereon,and PERMIT ISSUANCE
who contracts for such projects with a contraota(s)licensed pursuant India Contractor's pL9llR-DRAIN&VENT-WATER(GA
License Law. ) . '', " . : : nFEESUMMARY " -
❑ i nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT
#
DRAINS;FLOOR,ROOT,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Iherebyaerea thmlhrnavecrti certeoPoopytherof(Sec.380 ,preofifiLab)which FIXTURES-PER TRAP RECP.IPf#
Workere'Compensmlon lnsumnce ora certified copy thereof(Sec.3800,Lab CJ which PARK PCE Y N
covers all emploefL'snulm tI1Lv ors,lt GAS-EA.SYSTEM-1 INC.4 OUTLETS RP.CEIPT#
Policy# O( 0-IIU%T BUILDING DIVISION FEES
0 CaY ��Emmishow �.t^� GAS-EA.SYSTEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy is hereby fume city
❑ CertiFetl copy is fled with the city inspection division. GREASFANDUSTRI.WASTE IN CEPTOR GRADING FEE
CFJITIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not be completed lithe permit is foronehundred dollars($100) SEWER-SANITARY-ST MEA.200FU ENERGY FEE
crless.)
I certify thin in the peorn a ce of I crit rwhichmisproodiskst d,Ishall WATER HEATER W/V /ELP.CfR
not employ any pcon, ii i'y tan o become aof PAID
Compensation Laws of 4' n' Dam WATER SYS T EATING Dam Receipt#
O C) NOTICETOAPPLICANT:I,diet ma in this riticate of Esem t h uld NEW RESIDE AL PLMB. S FT.
pion,you s o Q TOTAL:
VJ become subject m the Workers Compens pro stuns of the Labor Code,you must
aforthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z thereby affirm that hem is a construction lending agency for the performance of
the work for which this pemilt is issued(Sec 3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
0 U Lend .Address QTY. `; MEC_HANICAGPERMIT „FEE,: PLUMBING FEE
I e ri fy that I have.read this application and state that the above informatio -
�"' 0.Wi cored 1 agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
�^ IA buildingconstruction,and hereby authorize representatives ofthis city menterupon the CONSTRUCTION TAX
L) y above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
rr77 (We)agree to save,indemnify and keep harmless the City of Cupertino ugoinst
bablliles,jui encs,avis and expenses x114 h may to any wayaeaue against said City AIR HANDLING UNIT G70 10,000 CPM)
conseyue qhs mOng width
f Ilii. pe nit
AIR HANDLING UNIT(OVER 10,00 CFM)
Signatureftllcare/Conwmor Date EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS M fiR1ALS DISCLOSURE HEATING UNIT(T010,000 BTU) Dale Rweipt#
Will the applicant or future building occupant such,m handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 TOTAL:
Code,Section 25532(¢)1
11 Yes ❑No ' ESVENTILATION FAN(SING
BOLTER-COMP(3HP O !MORE BTU) ISSUANCE DATE
• Will lheapplicanlorfmurebuildingoeoupont usoequipmentordevices which emit —e +.
hazardous air con armatois as defined by the Bay Area Air Quality Management BOILER-COMP( R 100,000 BTU)
DistncC
Ely. ❑No NEW RESIDE IAL MECI+ SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the n/�}'
MAY ^r 1 1994
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify thelrll Y fit- ,
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE