26447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY(IF CUPERTINO RUMB'IN'G-ME CIIANI A, PERMIT NO.
APPLICATION/PERMIT PING FROG C1111EANICAL 26447;6 4 4 7
IIUILDING DIVISION BUILDING PR(1JE(:1'IBEN'fIFICA'I'ION
BUILDING//AAf�51�311.55: ft^/ D SANITARY NO. APPLICATIONSUBMDTAI.DAIF.
160 O f24 UNIT# LOT#
O NERS NAME: //y� PHONE: ONTRA OR'SNAME: LIC NO: N/C COM'ROLM
lstm �. Au 4 SC"j
•A CIIITECf/ENGINF-LR: LIC NO: ADDRESS:
1 H
CONTACT: PHONE: Qom. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLD FILEg aP�LUaMI1
aB MEC
PERMIT ISSUANCE 17 1 PIS
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 30B DESCRIPflO
QbdZ I hereby affirm that l ore licensed under prodsime.fCTapmr9(cotmnencing with
u100_ Section]OX)of Division 3 of the Business and Professions Code,and my license is in PANELS
K"I�Y-�. full force and effect.
<UW 1-tow Class Lic.# IR T0200 AMPS
,Ajy Date Contractor 201-IBM AMPS SQ.FT.FLOOR AREA $/SQ.PI'.
ZOy� ARCHITECTS DECLARATION OVER IWO AMPS
CZ-0
I malco tanJ my plums shall be used us public mored,.
K ooF.WJ SIGNS ELECTRICAL
5..1 Licensed Professional
yK< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
I UI hereby,affirm that I am eaempt from the Convectors License Low for the
3 a y
following reason.(Section 7031.5,Business and Professions Code:Any city or coumy TEMP.METER OR POLE INST,
t f-�g which requires a permit m constrict,alter,improve,demolish,or repair any struclurc
pdo,ioiaissuance,also rcgnires tbeapplicant fimsuch pound 1.file asignW statement POWER DEVICES
oo
that he is licensed pursuant the provisions of the Contractor's License Law(Chapter
9(mmmcncing with Section]000)ofDivision 3 u(Ne Business erM Professions Code)
y O ttSWIMMING POOL ELECTRIC VALUATION
�LL.
uxi=w m that he is exempnherefrom and the bass,far the alleged exemption.Any violadonof OUTLET'S-SWITCHES-FIXTURES
F Z Q Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of
5=nnt mom than five hundred dolla a($500). NEW RESIDENTIAL ELECIR _SQ.FT.
col= ❑ 1,asawnerofthepr(lwny,rrmyemployees with wageamtheirsolecoaaoo
apare , STORMS TYPE CONSTRUCTION
wiltdothewmk,vdlhestmcmmisnwimendMoroffert forule(Sm.]04g,Buslness
and Professions Code:The Contractors License Law does not apply to an owner of
property who buildsorimproves thereon,and whodoessuchwork himulforthroughhis
OCC.GROUP RES.UNITS
employees,providedthatsueh improvementsseenot intended moffered fortole.IL
however.will have
ie bur improvement issoldwithin one year of completion,purpose of TOTALkFEE
builder will have the burden of proving that he did not M1uiIJ or improve for purpose of
:ala). QTY. PLUMBING PERMIT FLOOD ZONE APN
❑ I,asrwmer rl the property,am exclusively contracting with licensed ommortma'a
mmwa the project(Sea]014.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License Low does not apply to m owner of pom earty who builds m improves,hereon,and
whocontracts fmarchprojects with acunvecmr(s)hermedpursuant to the Controcmr'I AL - FEESUMMARY
License Law.
❑ 1 am exempt under gcq B&P C for this rcamn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Data ��#P#► ..I^a pp RECEIPT#
WORKMAN COMPENSATION DECLARATION D �aF//11 W eYTOOL TA% YN
• ❑ Ihemhyaffirmthmlkaveecenifwmo(corlscnuoselGinsum,orecertificamof R rv1' or er eee C Y-CL1ET# N—
W C..mpensainn Insurunca or acerifed copy thetwf(Sec.3809,Lab CJwhich rja�
ssp" wicorrecU add RF.CI:IPT#
ca,orsall cmpinyee's under this permit G BUILDING DIVISION PGLS
Policy# ��PYg��s
Company G aYtV ca MASON 0 1 PLANCHECK FEE
❑ CenifNcotyisherebyfumishol.
❑ Certified copy is fled with the city inspection division. IG
t1R GRADING FEE
CERTIPICATF.OF EXEMPTION FROM WORKERS' mod for 30 SOILS FIS
COMPENSATION INSURANCE
Mia section recd notberompinMif the Permit isfowne hundred dollars(SIM) NITARY 'I'ORM :A. ENERGY FEE
or loss.)
I maify that in the performance.(the weak for which this permit is issued,l shut[ Aram 4
wt employ any person in any manner so as to become subjat to the Workers PAID
Compensation Lawaof C.ifmmiu. Duro TEM/IRLATI G Date Receipt#
zApplicant
NOTICE TO APPLICANT:if,after making this Ceniftcammf Exemption,you shouldI TO PALhvanne subject 1.he Worker's Compensation pm visions of,hclaba Coda youmstLDINGFLET> forthwith comply with such Provisions or this permit shall be dea ned revoked.
Doi M
G Q CONSTRUCTION LENDING AGENCY E
I herebyaffnnthanhere iso construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sea.3f97,Civ.CJ
Lenders Name PLUMBING FEE
L
1'I"' F ceders Address QTY. MECHANICAL PERMIT FEE
U I ccnify that I have martins application and state that the show information is MECHANICAL FEE
>" correct[agree tocomply with ell city end wumy mrdinanas end tare laws rcladng to PERMIT ISSUANCE
F-' N building conswetion,und herchy autherim mptesenmtives ofthiscity to enter upon the CONSTRUCTIONTAX
(, z above mentioned property for lattice' purpmus. ALTERORADDTOMECH.
(Wc)agrte m save,indemnity antl cap
hamlets,he City of Cupertino against
l'abilities,judgments,costs and ex rtes Inch may in wy way accrue..gain..said City AIR HANDLING UNII'(T'010,090 CFM)
., ! in cmacq cc the granting is
AIR HANDLING UNIT(OVER 10,000 CFM)
igna d t — `Date EXHAUST HOOD ONMUM) PAID
HEATING UNIT JO 1(10.0011 BTU) Date Receipt#
BAZAR OUS MATERIALS DISCLOSURE
WdIlocipplicantmm remadingmccupam,too rhandlehazerdous material HEATING UNIT(OVER IW.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the I leehh and Safely
Cale.Section 25532(.)) VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the upplicantor future buildingmccuWtum equipmentordeviceswhichemit BOILER-COMP QHP OR 100,0011 BTU)
hauNous air continuum,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? P] p
❑Yes ❑No NF.W R[SIDENTIAL MECI1. SQ.FT. 1� i'9
I have mad the hazardous materials requirements under Chapter 6.95 of the
CJifnmiu Health&Safety Cmlc,SccJons 25503,25533 and 25534. 1undersanddha MAY 31 1994,
if the building does not currently have a annual,that it is my responsibility to notify the
occupant of the requirements which must la,met prior to issuance of a Cer-ificme of
Occupancy. C�IY
Owner or moluvim l agent Date TOTAL: ISSUED BY: '\,
OFFICE