25459 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Qfl'DINf'-}IUF7CTRICA' PERMITNO.
APPLICATION/PERMIT rl.umxlrvc.mE.CHANICAL 25459
BUILDING DIVISION BUILDING PROJECT IDENTI4TCATI(N
BUILDING O bG ADDRESS: _ �l�/ (�'3 SANITARY NO. APPLICATIONSSUBBME:
�I FIAT,DAT
IlA-)pLfC 44o.7/0 04 "I/ 7 UNIT# LOT G�ONl y\3
ORS NAME: PHONE: COM'RACFOR:S NAME: LIC NO: / NIC CONTROL#
WNhrEu/cEr/ �gc,rge0 _177 0529 e�lS�sa .A� LvvsT Co. 53/9/
ARCI I1TECf/ENGINEER: LIC NO: ADDRESS:
%7jo'wpAS �wa9�...J CaS3 /SZo nvsyA,.J ,' - X177 Suaa.aar�A�
CONTACT�:1 /S � PHONE:: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
"-AA4rFCES4XI tp -)y7-o341 P UM MECH
A EC ^ 957 PERMIT ISSUANCE El
LICENSED CONTRACTOR'S DECLARATIONAPPLIANCES-RESIDENTIAL
qyz I hereby affirm Thal l am licensed underprovisions of Chepter9(commencing with TOB DESCRIPTION
WOO Section 700(p of Division 3 ofthe Business and Professions Code,and my license is in PANELS
sU— full force effort C
azw Lineae Cross Lic.# S3/9/S UPTO200AMPs r J
F-j y Date Comr. U Y Q `�• 201-1000 AMPS S�Q,�,.
z O,z yeahall
ARCHITECTS DECLARATION OVER IBM AMPS (p�� 1p1'�'(�
P!nt-W 1 I% . nJ—Y�la�s�beplsed/ P'bRJi / ^.s SIGNS ELECTRICAL pw ■ l
�J Ere sal ro�fesionind !/s1 _--l'J_ - _
Wee< OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
X0 W, I beech,affirm that 1 am exempt from the Convenor's License Law for the
W 3 w h.y¢ following nam..(Section 9031.5.Business and Professions CW,Any city of..nty TEMP.METER OR POLE INST.
J which requires a perout re Consoam,alter,improve,demolish,or repair my swcmre
�WY� mitsi...ana,alm then licmt forsuch tto file.si ed statement POWER DEVICES
prior rryuitcs pp Ixnni Bn
COOpursuant ns
z that he is licensed pursuano the provisions of the Contractors License Law(Chapter ProfeSWIMMING POOL ELECTRIC VALUATION
Yp eve 9(commencing with Section 4000)of Division 3 ofthe Runless and ssions Cade)
or that he is exempt therefrom it the bssisfar the alleged exemption.Any violation of Oct
�za Section 9031.5 by any applicant for a Permit subjects the applicant o a civil penalty of OUTLETS-SWITCHES-FIXTURES
=O nonnorc than RvehunJred dollars(b51gk NEW RESIDENTIAL ELECB _SQ.FT. STORIES TYPBCONSTRUCT'ION
�Fm ❑ I,asowncrofthepropeny,ormYcmploYeeswimwagexssthcirsolecomperuation,
a3� will Jothewon,Coak: I he Cmeisnoti License
La does not
8144,Business
mJ Profession Cule:'1'he Cnntramor's License Law Jens not apply to m owner,of I -
pmpcny whobuildsuimproves themun,mdwhodces...hwork bimselforthrough liis
OCC.GROUP RES.UNITS
own employees,Provided Nat such improvememm sanot intendedwoffered formile.If,,
however,the building or improvement is sold within one year efcompletion,me owner-
builder will have the burden of placing that he did not build or improve for purpose of
odc')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
E] 1.as ownerufthe progeny,am exclusively contracting with licensed convectors to
consumer the Project(Sec.7054,Business and Professions Code:)The Convector's PERMIT ISSUANCE
License Law Jas not apply to an owner ofpropeny who builds or improves thW
ereon,m
who contracts forsuch projects with a ronwetor(s)licensed pulamo u i fi a Contractor's
License Law. ALTER-DRAIN&VENT-WA Bid(FA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this masongpCK FLOW PROTECT.DEVICE O SID ;ES
F
SANITARY V N
Owner Date DRAINS-FLOORROOF. GOND. RECEIVE#
WORKMAN COMPENSATION , . .DECLARATION SCHOOLTAX YN
�❑. I hereby affirm that l have aceniricate ofconsem loself-insure,or ucertifteamof FIXTURES-PER TRAPRECEIVE'.
Workers Compenmtionlmu corocenifiedcopYthereof(Sec.39W.Lab C.)which PARK FEE Y N
covers all employee's under this permit GAS-IIA.SYSTEM-1 INC.4 OUTLETS RECEIPO p
BUILDING DIVISION IDES
Policy#
Company GAS-EA.SYSTEM-OVER4 TAI PLANCHECK FEE 07
❑ Certified copy is hereby fumished.
❑ CertiliW copy is filed win the city inspection division. GREASIVINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Thissecfnabad nal becompletedENe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify than in the performance ofthe work for which this permit is issued,l shall WATER BEA'f1iR WNENT/ELECTR
nut employ any person th my manner sou} one su�1�r the Workers' PAID
Compensation Lawsof Caliromia. Dene J97/9l WATER SYSTF.M/IREATING Dae Rcccipt#
Z A lint I
Pp NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
O NOTICE TOct1.he ANT:IL Compensation
this carNOTICE TO APPLICANT:IL after making this Certificms ate h Exemption,you You outs,
- boromc.mbjmly the Workers Gimme or this
peount Sall beelabmevoed. must BUILDING FEE,
> fonM1with comply with such provisions or this pemlit shall be decmed revoked.
LETg (� CONS'T'RUCTION LENDING AGENCY SEISMIC FEE
I hereby amen that them is a construction leading agency for the perfonnana of
U z TOTAL EiLECTRIC FEE
the work fur which this permit is issued(Sec.3119],Civ.C.)
Lender's Nmnc PLUMBING FEE 1 �
I,. Lender's
Address QTY. MECHANICAL PERMIT FEC
0 V 1 certify that 1 have read this application and state that the above information is MECHANICAL FEE
correct. I ugme to comply with all city and county ordinances and.state laws misting m PERMIT ISSUANCE
.r--' (Z) building construction,end hereby authonae represeauuves ofthiscltY memeralron the CONSTRUCTION TAX
U z alae-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless me City of Cupemnn against 1
Iiabilities.judgmema,emm andexpenses which may in my way accrueagaint said City AIR HANDLING UNIT((T IB.(MCFM) V-
an
In umsequena of ma grting of ria pe.I'.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApphcanVContractor Date EXHAUST HOOD(W/DUCI) 'PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(1 B'TU) Date Receipt#
Will the applicant or future building eccupmt store or handle hazardous material HEATING UNIT(OVER Uxt BTU) 1
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cute,Section 25532(a)7 VENTILATION FAN(SINGLE RFSID) f
❑Yes W N. ISSUANCE DATE
Will thea lir torfummbuildin tuwe tordevicawhichemit BOILER-COMP DHP OR 104,010 BTU) p7 A '
pP Bmcuhe 9ui.Ail Il P1
Ila um," t Fred by the Bay Area Air Quality Mmugemem BOILER-COMP(OVER 100,000 BTII)
to etc u.m❑Yefiaminan s allo NEW RESIDENTIAL MECH. SQ.FT. AUG 17 1993
1 have rad the ImIalu a matenals reyuiremems under Chapter 6.95 of the
California Health&SaEery Code,Sections 25505,25533 and 25534.1 undenied that CITY Ur GUrCPII INV
II'the building docs not currently have a tenant,that it Is my responibillty to notify the
occupant of the re,quitr a which m he met poor m issuance of a Ce Bcme of
i
n m
owmen nn aumonma agenn / DT IssuED Br