26490 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECRI
TCAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26490
BUILDING DIVISION IIIIILDING PROJECI'IDENTIFICATION
BUILDING ADDRESS: �n /J ca nna Is IWD SANITARY NO. A(P/P1�LIC�A.TIIOOONNSUlrBMITTALDATE
� � J�N11
Ael V•� L / UNIT# LOT
OW ERS 1?: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL#
II
JbJIfA LSa cJ .245 7
RCHITECIU ;INEER: LIC NO: ADDRESS: ❑ 07.a7?
CONTACT: �aPHONE: 783¢ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
7
�+-a��TT•J1'J � sn��T' _ BLpG sLl: P UMO i
Ride?GL
PERMIT ISSUANCE I 1W'�aj
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OCZ Ihereby affirt l amlicensed underpmvisionsof Chaprer9(cormnencingwith JOB DESC IPI'ION
mtha
In00 Section]00TO Division 3 ofthe Business and Professions Cale,and my license is in PANELS
FE bE Ines farce and effect.
6FZ License Class Lie,k UP TO 2W AMPS �f'1
rfn- y Dote Camuxrrm 201-I"AMPS �h'v
ZHE; ARCHITECTOVER AMPS S DECLARATION SQ.FT.ITO AREA S/SQ.FT.
O Zy— 1 understand my plans shall be used as public rewrds.
F, F-� SIGNSELECTRICAL ELECTRICAL /b
iE Licensed Professional
C OWNER-BUILDER m the CoATION SPECIAL CIRCWT/MISC.
00.0 Ihereby uftlrm thin 1 an excmpr from the Commuter.License Law f.T the
W 3 oo which ngm..fre ant 1.construct,
Rumness and improve,
demolish.
e io li Cad,:Any city o nonnere TEMP.METE0.0R POLE INS'(.
waJ whichrequiresapermit requires tealter,imfor such
Jamuah,ore a sig edawmurc
f't,�T0
prior to its sireased pursuant
to the
Nevisios for Co#emotes Licese La statement POWER DEVICES
A.C p thin he is liansai pursuant to the pmvixions of the Cmnracmra License Law(Chapter
d4ea 9(commrecingwah Section 1000)of Division 3 ofthe Buainessend fes sCcd,) SWIMMING POOL ELECTRIC VALUATION
W^y or Cher M1e isemmpnhercfrom and the basiafor the allegedexemP' n.Anyviol� not
O /�'� r"
a Section 0031.5 by nny applicant for.pe.nit,ubjc...the appli nun ecivil penult f UTLETS-SWITCHES-FIXTURES
G
not more than rive hundred dollars($500). J J.
❑ I,soweer.Dhe Xr rty,ormyemployeeswiNwo It at NEW RESIDPNTIALELECfR _SQ,FT. STORIES I TYPE CONSTRUCTION
R3: willdothework,and the structure isnot inendedormf for aISee.?(k4,Bu meas
and Profession,Code:The Contractor's Licens w does nce #ply to an ocr f
propertym
whabuildsor impvrc
rathean.and odors suchwo selfor ,x
wnemployces,providedthaisuchimpr mntearen thorn afer Is.I OCC.GROUP RES.UNITS
however,the building m multove tswldwithiam, nmplst - O
huilder wi 11 have the burden.( m,inglhathedidrowle n n,pmve to Z carp se of
ag
le.). TY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Las.wnerofthrumpen amexdusivelycomen t ith l' ncuacmtstu
construct the project(Sec.? ,Business and N ' s C e: TB Conh...... PERMIT ISSUANCE
License Lawdoesno apply m no wnerofpmpesy ob 1 1m xdemov,an
wbmcon.ecnftn suchpmjeaswit ocomtrac 'c used pur]yt It the Conrnct a ALTER Law. "� WATER IEA) FEE SUMMARY
❑ I i m exempt ands'Sec. B&P C for thio BACK FLOW PROTECT.DEVICE '• DE FEES
SANITARY Y N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPPNSA'fl DECLARATION SCHOOLTAX YN
I hereby am.thatlhsveaccnifcam ofCo mtosslf-insum,ore ifcamof RECEIPT#
I brke,a'Companaation lraurence orottnificdeapy zrro See.JSW. C.)which FIXTURES-PER TRAP PARK FEE Y N
Covers sit employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTM
Pulley If BUILDING DIVISION PEES
Company GAS-IIA.SYSTEM-OVER PLANCHECK FEE
ClCrnified copy is hereby forobbed.
❑ Certified copy is Rled with the city inspection Jivieion. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF[MiMPI'ION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forms,hundred dollars(EIW) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE .r
less.
I certify that in the performanceofthe work for which this permit is issued,I shell WATER I[EAT'ER W/VENTELI?CTR
not employ any person in any manner so as to become subject be the Workers' PAID
Compensation Lawsof C.lifenou Date WATER SYSTEMITREATING Data Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT.If,atter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
(q become subject n the Workefs Compensation provisions of the labor Cards,you must BUILDING FEE
forthwith comply with such provisions or this permit shall he deemed revoked.
Lkl r--t
CONSTRUCTION LENDING AGENCY S171SMIC FEE %10
5 z I hereby affirm that there is i sued(S .construction lending.Caney for she Performance of
U O the work for which this permit is issued(Sec.JW7.Civ,CJ AL: ELECT0.IC FEE
Lendei x Noe PLUMBING FEE
Q U
Lender's Address QTY. MECHANICAL PI,RMIT FEB
Iartify that 1 have read Nis application and state that the above information is MECHANICAL M17F CWi correct. l agree to comply with all city and County columnists and slate laws relatingm PERMITISSUANCE
huiWingcmnstr hereby amhodze represenmtivesoftlds city to enter upon the GONBTRGC'1'IQN'TAX
V 7 uMwe-menti cA#'open for inspection puryoses. Is ALTER OR ADD TO MECII. �
C (We) grte to_-Pe indemnify and keep hamdess the City of Cupertino against — A�_
Bari
scoamand hmayinanywayacerva.,mtsaid Cit AIR HANDLING UNIT(TO If"CFM)
I cone ce Conti of this panni
AIR HANDLING UNIT(OVER IgBW CFM)
SiArr ra ant Data EXI IAI1ST GOOD(W/DUCT) PAID
gn
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW.WO BTU) Data Receipt#
Will the applicant or future building occupant seem or handle h urardous material HEATING UNIT(OVER I W,(100 BTU) TOTA '
as defined de,by the Cupertino Municipal CaChapter 9.12,and the Health and Safety
Cut Section 25532(e)? 11-41
VENTILATION PAN(SINGLE RPSID) tet Sf ) LSU
11 Yea ❑No
Will he applicant or future building mcupant esu m.'devices which emit
BOILRR.COMP(3HPOR IW,WO BTU) ISSUA CE ATE
m 0?,ab ranwminanta as defined by the Bay Area Air Quality Management BOILER.COMP(OVER 100,0)0 BTU) JUL 25 1994
rict?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FI'.
I have read the hazardous moeriub requirements under Chapter 6.95 of the CI I Y Ur Garen I BVU
California Health A Safety Cade,Sections 25505,25533 and 25534. 1 understand that
if the building does not curentlyhave omm,m,thinitismyrsuance of. rinficat the
cupnnt of the rcyuiremems which must tw met prior m issuance of s Cenifmutc of
Occupancy. \��\ ���// ��//))
Owner or authorised agent Date T ISSUED B
OFFICE