25092NPPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILD TNG•MECHA ICA I PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT �v way PLUNKING-MF.CIIANICAL
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PERMIT ISSUANCE
BLDG ELECT 'r'..Tj�TMD MECII
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LICENSED CONTRACTOR'S DECLARATION
Ihemby affmtthe,I am lidneed andcrproviaions ern@aMcr9(commrncin6 with
APPLIANCES-PESIDENTIAL
JOB DESCRIPTION
Qew-0 l L (v
Sanson T00o)of DivisionJof to Business ones Profruions Code, ones my license is in
full force sad eRcb.
f ers C.ts Lie#
Commcmr
ppNElg
upm2uoAMPE
201- 1000 AMPS
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Date
ARCHITECTS DECLARATION
I understand my plans shill be used u public roomdc.
5�� 1-T��T.00R pR/W ■
T f"1 pC y\Vg
• r -'Y Ifs— ��J II�
1�
E/SQ, F
OVER 1000 AMPS /
SIGNS ELECTRICAL ��
Licensed RoreuiorW
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OWNER-BULLDER DECLARATION
1 hmcby affirm that 1 w aserept from the Canmmars License law for to
following rwon.ISabkm 2031.5. Business and Pmfinders Code: My city m county
Which mune. permit in croswa mer. improve. demolish, in repair any structure
Few roits issuance, alwbauvuthe applicant for each Permit tofileasigrmilmoomwt
that he u licrnud pumuant in the provisions of to CaresctMs U. Law (Chapter
9(comnsencing wit Santa. of Division 3 of to Business and Professions Code)
or thin he is remain tcrefram said to bush, far to alleged exemption. An, violnionof
Sedan'/OJl3by myappfimmfoe aparent subjects dmapplicamtbuaci,ilpeaaltyof
std mons: than five hundred &It. (SSW). 1.
❑ Lesownetoftopropehy.ommyrmployaeswitwagmutelrwlecompenwauon,
SPECW.CIRCUIT/MISC.
1_
Y
YY 1
TEMP. METER OR POLE INST.
POWER DEVICES DA
SWIMMING POOL ELECTRIC
VALUATION
Q UD
OUTLETS. SWTICIIFS- FWTURUES
NEW RESIDENTIAL ELECTR _SQ. FI'.
STORIES TYPE C NS'IRU(
will doth W.Amaildbe structural, ren endMoroffetNfmWc(Ex.LD41. Bush.
and Prelasidss Code: The Convectors License law dons stat apply in an owner of
pmpenywhobuildsorimpwvestemogand whodonwchwork hist.elfordbroughlds
own employees. provided to wch improvemmu ate nob intended err offered for wal e. If.
OCC. GROUP RES. UNIT!
- TOTAL:
however.the Euildingmimproveasnt is said widtinoneye:rofcompletion, Ibeowma.
Insiderwill have to burdentof, oving that he did act build or improve for purpose ofheo
❑ I,uawrcro(thmpvpery,emesclwivel convacun Witlianaed mnbiectonte
FLOOD ZONE APN
y� �A, menrn uymrmh+
_ O10. OPBRMIT.
!
tvmbiuer w not (See. L044, Business end y who ims Cade:) Lha ffi bi n, and
Ucatwlawdannotepplymwownerof property whobuilds mimpmvcatercon,ead
PERMIT ISSUANCE
wbocmbiwssforat projeaawit acontmctor(Olicaiud pursuant tote Conuectm's
LiLave law. . :':
❑ 1 am eaeabpt under Sm.' . B & P C for this mason
AV.WATER (FA)
ALTER-DRAMI'M
r t #e''�t xPEB SUMMARYe(
_
BACK FLOW PROTECT. DEVICE-
SANRARY Y N
Owty .a D.—RECEIPT#
WORKMANDRAINS
COMPENSATION DECLARATION
-FLOOR ROOF. AREA. COND.
r,
SCHOOL TAX Y N_;,
'-
]Thereby effuse tetlluveacniRcele ofcoment towlf-insum.memrufiute of
imkai Camvpeavtion NswancedednifMmpy temof(Sa. JIM. Lab C.) which
mvm all employee's undo his permit.
Policy# ^''
ply(.pGgFs-PERTMP
RECEIPT#
PARK FEE Y N_'
RECEIPTM
GAS - EA. SYSTEM-] INC. 40UTLETS
BUILDING DIVISION FEES
Company
GAS - IA SYSTEM-0VER 4 (EA)
PLANCHECK FEE
❑ Catifsed copy u heresy furnished.
GREASE/WDUSI'RL WASTE INTERCEPTOR
GRADING FEE
❑ Caufed copybfled wit to city imperuon division.
GREASETRAP
SOILS FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
SEWER.SANITARY - STORM EA. 200FT.
ENERGY FEE
(TNsseeuan need nabe completed ifte permit is forone hundred dollars(SIM)
or less)
WATER NEATER W/VENT/ELECfR
' Imtify don in to pcfomameof to Work fm which this pe mut is issued, )shall
not employ any person b say manner in, u to thco m, subject to th Workers
PAID
Z
Compoeximt Lewaof Califmnis Data
AMID.
WATER SYSTEM/TREATING
pate Receipt #
Q NOTICE TO APPLICANT. If, after melding this Certificate of Eaastpuon, you should
NEW RESIDENTIAL PLMB. SQ. Fp.
TOTAL-
OTALV)
V)become subjet to to Wonders Compartmetpmvisiors of to labor Cade, you most,
forthwith comply wit wch provisions or tis permit slWho
l domed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUMON LENDING AGENCY
Z I hereby whtaffirm that 0vre'u a cued (Sec. 3097, lending agency Ceacy (m to perfmmwce of
O to Wmk far Wh11LI1 tet pemN1161S5ued ($6. J89i, f.'IV. G,)
IardCrs Name
Leader's Address:
1 I mni(Y tat 1 have ted tis eppliwlion sad sone tat to above infmmebion is
coa I agree to comply with w
mmall city and county ordindsum laws and slaws nabbing to
building combination, and hamby autonae representatives of tis cit"o enter upon to
Z ebmve-meamm ed property far inspection purposes
TOTAL:
ELECTRIC HE
easnr.c-rH4
,Nr s,�twiBCEIANICAl.'PERMITy .FEB
""aIX` ' `q-c'znk'0'"aats'0 ``''
PLUMBING E
FE
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
AIR HANDLING UNIT M 10." CFM)
(We) agree to wave, indemnify and limp hermleas to City of Cupertino against
r liabiln dimer., costs pensee. which may in my way acme ageimt aid City
in con _ tt rr,n muni �f ty glmmib.
rV4T
AIR HANDLING UNIT (OVER IO,WO CFM)
n�j1z'' T/�/p-¢�Sl{\ Cit L4•
Stgttatu Con ser Dam
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
11ne Receipt#
Will to applicant in future building occupant atom or handle haeardous material
u dcfned by to Cupcnmo Municipal Code, Chapter 9.12. and the Health and Safety
HEATING UNIT(OVER IW,WO BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Cad , Section 25532(W
❑ yet 1:1No
ISSUANCE DATE '
_
Will teapplicammfummbuildingmcupwtusee uipmemardeviceswhichemib
INous air counumbem. u dcfned by the Be, Arco Air Quality Management
�. in?
BOILER - COMP(JHP OR 100.D00 OTU)
pp
;� N1 Q
BOILER - COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECH.—SQ. FT.
❑ yes ❑ No
ad the herdous materials resluiremenunder Chapter 6.95 of to
I have mum
MAY 19 1993
Glfmmis Holt & Safety Code. Sarni. 505.25533 and 2 534. I undersand that
irtebuillilr,,joe tcurr"ady sem t, that it is my mspona ibiflirymnatifyte
tvcup�an s/ ia] vgtisjt met perm m iuuume of . Cpenipfrmte of
`I r) y �t b t l l ss '
sneny
cera L{JL. ' AI �1yf
3
1��ktee�`
ISSUED BY:
a
Owncrm tnnud agcni— Data
TOTAL: