24962 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL 24962
n 9 C n
BUILDING PROJECT IIIENTIFICAI'ION G L� o L
BUILDINNGGAPDRES./ 1I SANI'T'ARY NO. APPI.ICA11ON SUBMITTAL DATE r 1/C� v—,(/1 UNI 14 LOT
M t `OWNF fAMLQ �QBHONE: &_ / CO AMO 'S NAMEC��
�., 4Af/NAM N/C CONTROL#
�'f11TECT GINF.I:R: LICNO: AI1,�5$:� �/ ❑
-�CONTACT: PHONE: ,[{C_C� I BU
QTY. ELECTRIC PERMIT FEE ILDING PERMIT INFO
PHRMIT ISSUANCE B ELECT PLUMB MUCH
El El ❑
LICENSED CONTRACTOR'S DIiCLARATION gppLIANCF.S-RESIDCNTIAI. `1-K'-9 L 081p:; glj']]O`� 1�
140.0 Thereby of Divisiefladon
3 of the
Basins and
Code,
and mmencise with __0',`a�'(_ RH,v--"W_1T1
1400
FO inn(.race e"itG)eff�vision3of the Business and Pmfcasiom code.end my licca.is in PANELS 214-fs�y( (���kyk�'1 iUIhS YD/��,,"�.1
E�-gj�zyl Licence Cl Lic.p sw33-9 UPT0200AMPS 05; --It+,l1 M/ `bve$9t5M3` �I
m6c. Dale�Cambadn, 201-1(NMI AMPS
Fye ARCHITECTS DECLARATION nco its ^ POR iltl?A_ S/SQ.IT.
OVER IOfN1AMPS p N
���jjj lundecnanJ my plans shall beused os puM1lic recoMs. I'
Y
Licensed PSIGNS ELECTRICAL
C rofessional
X
OWNER-BUILDERDECLARATION SPECIAL CIRCllIT/MISC.Oaon 1 hereby affirm thin I nm exemptexempt from the Contractors ,:Ar, l.vw for the
w3Oy followingmas,aermii to 7031.5.constrct.All,iand mprove,
demolish,
Co dc:Anycity orcnunry ILMP.METER OR POLE,INST. '
�sSyg which rcquiresapermit to canstrveLaper.impmve,Jemnlish,or spear any structure POWER DEVICES
}C) that hofs licensed pursuant to th the provisions
filhe Contractors
License
La .Cement
4aj Op thin he isncin with
tot )offsionsnf the C.mmmors License Law(Chapter
9(romma.dng with 9cninn lOW).f Divisinn3of the Business and Professions Cale) SWIMMING POOL ELECTRIC
VALUATION
w_rn Secbut tion 7031.5exempt
nyappomand the bmisronhetsthedexempst to civil mann of OUTLETS-SWITCHES-PDTURES /
1..0Qnot
Section sea for a s.M1ja[s the epplicnnno.civil penehy,of
^� 14
not inert than Fee hundred dollars(5500).
tY�o 0 75-
[I I,asownerofthcpropeny.ormyemploycawithwegaestheistet<compemeti.n, NEW RESIDFNTIAL[LGCsIt _SQ.FT. STORIES TYPE CONSTRUCTION
a3e' will do the work.and the structure isnotamended mofferW forsale(Sex.]044,Business
and Professions Cade:The Contractor's License Loo does not apply to an owner of
propmywhobuildsorimprnves thereco,end whodoes such work hinew1forOvough his
own employees,provided that wchimpowemenes are not mandedoroffmnl Inside.If, OCC.GROUP ERES.UNIISh waver,the building.,improvement le told wilannneyenr nfmmpletion,Ill .wins, TOTAL:huilder will have the harden n(proving that he hit not build or improve for pu#urea ofsole.).
El Lmownesofthepn)pony,emexclusivelyconsmeiiMwiNlicenecontmemrsto- QTY. PLUMBING PERMIT FEEPLOO ZZONE
comtrua the pmjeci(Sec.7041,Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License «
Lewdsnot apply totalownerofproperty whobuilds.r improveethceson,and
who contracts Gorsuch projects with ac.nsmctores)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I an exempt under Sec. ,B&P C for this reason
BACK FLOW PROTECT.DEVICE SANITARY Y N
`16,
,.:.,;Iwner Dam DRAINS.FLOOR,ROOF,AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ih<reby affirm thmlhvveecertifcas ofconsent to self-ins ure,.racenifice[e of RFCMi1PT#
Workers'Com MIXTURES-PER TRAP
pensmithat Ihvea certificate
ofcosent toselfSec.m,or Lab Cficate f PARK FIiC Y N
covers all employees under this permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RFCEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-P.A.SYSTEM-OVER 4(BA) PLANCHECK FEE
❑ Certified copy is hereby bombast.
❑ Certified copy is fled with the city inspemion division. GRHASENDIJSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION IROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseetionn«d notbemmpletedifshepemtitis torose hundred dollars(SIM) SEWER-SANITARY-STORM FA.203FT. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this permit isissued.)shall WATER HEATER W/VENT/EL=R
not employ any rson 'n any manner eo�h#ugne�"to the Workers' PAID
Cnmpcnxall LL LL lJ WATIiR SYSTEM?REATING Date ItcceiptN
Q z Appllcvn - �D�s.-ra.
z � NO"I'ICET6APPLICAN'F:If,v rmaking this CnificamofExemption,you should N17WREMDENfIALPLMB. SQ,FT. TOTAL:
rrA became subject to the Worker's o 1,mention provisions of the labor Code,you must
� > forthwith comply with such provisions or this permit shallbe dmmod revoked. BUILDING FEE A
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FTH 1
Vz I hereby affirm that there is a construction lending agency for the performance of
O the work far which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
LZ. (.r Lcuders Name -
O U I.enders Address QTY MKIIANICALPERMIT g. FEE -" ` PLUMBING FEE
L) I certify that 1 have read this application and nate that the above nomination I,
correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECIIANICALFEE
F-' building construction,and hereby vuNorim represenativea oftbiscity income upon she
V Z above-mentioned property for inspection purposes. ALTERORADDTOMECII. CONSTRUCGON TAX
(We)agree m save,indemnify and k p bertnless Ne City of Cupertino against
liabilities,judgmcnts,enstswdexi ns ch may in an way eccrveegeinst said Ciry AIR HANDLING UNIT(TO IO,BB)CFM)
co a run' .f ,mit.
ZD AIR HANDLING UNIT(OVER 10,000 CFM))
Signature of Appliesno actor Date EXHAUST HOOD GVMUCD
�� PAID
I ZARDGUSMATERIAL.SDISCLOSURE IIEATINGUNIT(TO100,000BTI)) Date Receipt#
Will the up 'am or(mare building occ.pam oma or handle haza,dnus material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HFATING UNIT(OVER 100,(X10 BTU) TOTAL:
Code,Section 25532(.)! 1 11
❑Yes 0 N VENTILATION FAN(SINGLERESID)
Will the upplicanlarfmure huilding oeeupanmaequipmenmrdeviocs which unit BOILER-COMP LHP OR 110,000 BTU)
ISSUANCE DATE
hazardous air contaminants us defined by the Day Arco Air Quality Management BOILER-COMPOVER IM,IXq BTU) PAID D
"slnrictl 11PN i
(
�. Y<s ❑No NEW RESIDENTIAL MUCH. SQ.FT.
I have mad the hazardous materials requirements under Chapter 6.95 of the ,APR q1 2 1993
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that
if the building docs not currently have a tenant,that it is my responsibility tu notify the
occupant of the er,mortnems which mast be out pri.,to I......a of u Ccdifwm ofV
OF ret pp Kl INV
C1wOccupancy, 1V
Owner or authorized.gem Dale TOTAL: ISSUED BY:
OF