24999 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOnLmDING-KLLUIKrUAL. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL q (]
BUILDING DIVISION BUILDING I'ROJEC4 (]'TIDEN'I'IFICATION J J
BUILDINGA/�%{pRISS: SANITARY NO]APPIACATIGNSUBMITTAL DATE
P404
UNIT# LOT#
O In I. PHONE � CO lys NAME: V LIC NO:
V PVJ 7 / N/C CONTp
ROL
RCIIITECI'/E GI F.ER: I.ICNIC, ADDR C OK 3a76 s_r 95,.s
COMPACTPHONE: QTY. ELECTRIC PERMIT FEF, BUILDING PERMITINFO
BW ELEM. PLUMB MECH
PERMIT ISSUANCE El ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOE DESCRIPTION
7Qxz I herebyeffin that l an licensedurchrprovisionsof0uper9(commencing with1ECW0[ Section7N)Pof DivisionJof the Boainessand Professions Corporal my license is is PANELS
full TUU Liorp roeandeffecm. UP TO 200 AMPS CIPN-\Ns.L�Q
F Z,a License Class Lin. (CX L
m 4=y Date Convnumr 201-1000 AMPSS
ZOinZ ARCHITEM'S DECLARATION Q'
FT.FLOOR AREA $/SQ.rr'
0 Z,- 1 understand my plans mall be used as public records. OVER 1000 AMPS
G rn�-W SIGNS ELECTRICAL
6 E:1 Licensed Professional
°S' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I hereby of nu mut 1 am exempt from the Contractors License Law for the
yl3
C,a following resonant(Section 7031.5,Business and Professions Cale:Any airy oreouny, TEMP.METER OR POLE MIST.
�J O.1 which rogaims a permit in non.met,alley,improve,demelish,er repair any inpure
poor to its issuance.alsorequires the applicant for such permit to fleasilaudsm.ment POWER DEVICES
W%<C) firm he is licensed pursuant to the provisions of the Compactor's License Law(Chapter
p'qX pX 9(mmmmmlag with Secmien]0110),Division 3efthe Businessand Professions Cade) 9WIMMNG E.B VALUA'TIOgp
Wim or that he isexempf fhercfrem it do,basis for the alleged exemption.Any violialmnof - -
t Section?031.5 by any applicant for a permit subjects the applicantto a civil penalty ofOIIrLEfS-SW CIIL•Snot more than five hundred dollars(S5010. NEW RESID LELECTR _S .K o ❑ I,asownerofnheprnperty,nrmyemployaswith wu"csas theirsolecampensatian, TYPF:CONSTRl1CT10N
wil l do The workand the structure is not intended or offered for sale(SecA044.Business DATEand Prnfessions Code:The Commeu is License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselforthrough hisemployees,provided that such impmvemenlsmmnot imemdedorofferod forsid,if, RFS.UNITS
however.the building or improvement is cold within one year ofoompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
salt.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lasoe purport
prop erty,amexinsively Prificrumn,CWe:rrmcontmnorsm
comsnet The project(Sec.]044.Business pe ywhoeiens Crimp The Ceriumoo's
whoc mmety oersuch apply to anowncndproperty whosed ds pursuant
nothc Contimeend PERMI'I'ISS(IANCTi
whoco],a..forsoch projects with aconwcmKs)licenced punuenuothe Conwcmrs ALTER-DRAIN&VENT-WATER(FA) FEE SUMMARY
Llanso Luw.
-❑ I an exempt under Sec. ,B&P C for this reason1 TS1Dh 'EE,
BACK FLOW PROTIiCT.DEVICE SANITARY Y N
Owner Date DRAINS-FLOOR,NOOP.AREA,GOND. RECEIM'p
WORKMAN COMPENSATION DECLARATION SCHOOL'I'AX Y N
ID Ihcrchy affirm lhaflhave ucertifwm of cnnsem to self-insure,oro certifeute of FIXTURES-PER TRAP RECEIP a
Woolen'Compensation Insurance or a certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N
covers all employe', oder this penin. GAS-PA.SYSTEM-1 INCA OIDLEI'S RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ 5grinflid copy is hereby famished.
Cc onfied copy is fled with the city inspection division. GREASPANDUSTRI,WASTE INTERCEPTOR GRADING FET,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFi SETRAP SOILS FIE
COMPENSATION INSURANCE
(This senionneednom be completed ifthe action is formic hundreddo11an($100) SEWER-SANITARY-STORM HA.200In, ENERGY FEE
or less.)
I certify that in the performance ofnhe work for which this permit is nicest.I shall WATER HEATER W/VENT/ELECI'R
not employ any person in any mapper so as to become subject no the Workei% PAID
Z CompensmkmLmvsof Ceifomiu. Dam T
WAER SYSI ENVIREATING Dam Receipt#
Applicant
Z NOTICE TO APPLICANT:If,after making this Certifcane Of Exemption,you should NEW RESIDENTIAL PLACE. SQ.FT. TOIAL:
1-+ become subjxf to the Worker's Compensation provisions of the Labor Code,you must
a forthwith comply withsuch provisions or this penin shall be deposal revoked. BUILDING PEE
WSEISMIC FEE �)
6. [] CONSTRUCTION LENDING AGENCY
Uz T hereby affirm tatthem is a construction lending agency for she performance of nTOTAL: ELECTRIC FEE
O The work for which this Permit is issued(See.3(19],Civ.CJ
Isnders Name
OF Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 nMify that 1 have read this application and score That he above immnmion is
correct.l agree to comply wish all city and coumymiblinces and ram laws retrain". PERMIT ISSUANCE MECHANICAL FEE
Ll� building cnnstrinn,and hereby uufhnrize represemm�ives offhisciry moaner uponfhe CONSTRUCTION TAX
U Z above-meni c o ,for inspection pufprscs. ALTER OR ADD TO MECI t.
We a" m save,indent keep h:umless the Ciry of Cupertino ugaina
Iiabili0 , mcns,Cr,smsa ,which may in'ryway.cc.c o'eirnsaid City AIR IIANDLINGUNTT(TO 10,000CFM)
are queece of the"r sppenh.
AIR tIAND1.ING UNIT(OVER 10,000 CFM)
fgnamreof APP c t nn EXHAUST HOOD(W/DUCf)
PAID
HAZARDOUS MATERIA. momhndi
HEATING UNITJO 100000BTU) Da. RMeipm#
Will nhee licann ar fumrc builAing oecu m snore of bundle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
ns defnml byl aCuPnrtino Munielpel Cnde,Chaptm 9.12,and that llenlmh and Smlafy
Code,Section 255320)'f
❑Yes ❑No VENTILATION PAN(SINGLE RISIO)
BOILER-COMP(3HP OR 100000 BTU) ISSUANCE DATE
Will lheapplicanm roofmurchuildingacupantuse equim
peor
mdevic<swhich ,
emif pp
hnzmdnns air cnmaminants as defned by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTTn P A I D
nlamp'r
es ❑No NEW RESIDENTIAL MECIL SQ.IT. APR 231993
1 h Q,mly
aterials requirements under Chnpl ,6.95 of the
ifoom alfhctions 25503,255]3 and 25534. 1undemmand ober
'The buil m"J ee nfnna i Jut if ix my reslmnsihility to nrnify the Fill T yr l,uren uivu
cup" of the m be met prior no issuance m a Certifcaneof
y.
Owner oozed ,at Date TOTAL: ISSUED BY: 'A ra Vu-