24943 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BI ILDING-ELRCfRICAL PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING.MECHANICAL �— 9 A 9 4 3
IIUILDING PROSECT]DEN'FIF'ICA'1'[ON
BUILDING ADDRESS: SANITARY NO. APP6ICATIONSUBMTITALDATE
1I
IO`CZv 11,1. V l x'C1 UNIT# LOT# Jay 3
OWNERS NAME PHONE: CO A S AM13: LIC NO:
NIC CONTROL#
IS AR LTC/ENG N' LIC NO: ADDRESS:.Z//LLO W.
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �. ❑ 6 o
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL pppJJJ¢��[��1Y
Ihereb fDa,catlamlicenR under P ( ei,in G 14 -�
Cm2 la pravisiamnfCTu mr9 mmmcncin W v
�00 Smion]IlW)of Divisitm3 off Byyggy pp$yeas orry Code,and my license is in PANELS
WUG full force and of c L4/'IV MryZRO�s�'1
FZy) Licrnsa Lic.q .'1✓ UPT02W AMPS
m<c. Dam Contractor 201-1000 AMPS
ZOryz' ARCHITECTS DECLARATION SQ.FT.E�OOR AREA S/SQ.FT.•
O Z,_G I understand my plans shall be used as public records. OVER 1000 AMPS �g`\Vg,
�4Fu,l SIGNS ELECTRICAL —.
,....J.1l1 Licensed Professional
J�qI< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M G Ilt-.1i
LLa 1 hereby affirm that I am exempt from the Ccsomasorn License law for the
LLOm following rcnsoa(Section 703 1.5,Business and ProfessionsCWc:Any city or county TEMP.METER OR EINSq'.n
y which requires a permit m commuct,Wier,improve,demolish,or repair any awcturt
Y£ pdmmits issuance,alsorequires the applicant for such omit to file a signed statement POWER DEVICES WA
<p chefmisncinudpunction7 e)ofDvision the Ce Business
asins License Professions
d o�' union omm isexemith Section9(10[pat Division tattle Busine.,sta.Any viola Cod of SWIMMING POOL ELECTRIC yplU
Sexrmheis1.5b, fhnefrem t far.it the bmmfor0eom floJ exemption. civilprAt,of OUTLETS-SWITCHES-FIXTURES 1
��Y Sec tion ID3L56ya undredidoll. $permit subjenuhe aPPlicunuoacivil penalty of /
G not mart man fixe n.narta amlara(sslro).
r� NEW RFSII7F:NTIAL ELLCfR _SQ.FT. STORIES TYPE CONSTRUCTION
C� ❑ hmowtterafthepropmy,ormyemployces withwegesmthcirsalecompensation,
BL willdo the work.mdthe auuctureimmimendW ornffcreJ tarsale(Sca7f144,Business
and Professions Cede:The Contractors L.icensc law docs not apply m un owner of
pmperty whobuilchorimproves therm,andwhodoessuchwork himselforthrough his OCG.GROUP RES,
wn employees,providd shot such ins prov emmt s ore not i me nJed nr offered for sale.If.
however,the building or improvement is said within one year ofenmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build of improve for purpose of
xulf.).
❑ I,as ownermthe property,am exclusively connecting with licensed c.mrsomrm QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
emuuct th.,.jcx,(Sm.7044,Business and Professions Cade:)The C.amico n'. FFRMI'I'ISSUANCE •�
License lawdoes notapply m an ownerofpropeny whabuildsorimpoweatherean,and
who contract.forsuch projmir with.comostor(W licensed poommlto the Comraaor's -DRAIN&VENT-WATER G
License law, ALTER (EAT PEE SUMMARY
❑ I wn exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE SANITARY
SIDE S
SANITARY Y N
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
❑ I hereby affmr that l have a cinificate ofconsent to self-inmra or a certificate M FIXTURES-PER TRAP RECEIPTp
Wmiuma,Compensmion lmurat m.certified copy thercof(Sec.7800,Luh C.)which PARK FEE Y N
covers At lr 'r t ' -f GAS-EA.SYSTF.M41NC.4 OUTLETS RECISION
covers G BUILDING DIVISION FEES
Company 1, U GAS-FA.SYSTEM-OVER 4IRA) PLANCHECK FEL'
❑ ified copy is herby famished.
Cenifd copy is filed with the city inspection division. GRFASEJINDUS9RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forone hundred dellen(TIDO) SHWER-SANITARY-STORM EA.200PT. ENERGY FEE
or less)
I certify that in the performancesftle work forwhich thiaperaff is issued,IabWl WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Wmkes% PAID
Z Compemmionlawsof Criblomia. Dam WATER SYSTEMTREVDNG Date Receipt#
Applicant
2 Q NOTICE TO APPLICANT:If,after melon,thio Cerdfcateof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
LO) became subject to the Worker's Compensation provisions ofthe Lubar Code,you must
a , forth vuh comply with such provisions or chis penfor shall be deemed revoked. BUILDING FEE qiy, �
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE ,
Vz I hcrebyaffimtthanheroB.c.muctmir lendin,ripiryfolhe performanceid TOTAL: ELECTRIC FEE
0 the work far which his permit is issued(Sec.3097,Civ.C)
r.. Lenders Name
C) [U+ Lenders Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
(•111 certify that I have red this application and suite that Ne aMve information is MECHANICAL FEE
0.
correct. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
f
building construction,and hereby audition representatives of thiscity toenter upon the n CONSTRUCTIONTAX
L) z above-mentioned propmyfor inspection urpo
purposes. ALTER OR ADD TO MT:CH.
( rts
(We)ugto save,indemnifynify ad
kap sthe City of Cr against —
Iinbilifies,judgmcnt.,cosnnnd expensmw hma,miny way ncauefigmn,xaid City
AIR HANDLING UNIT(TO 10,00(1 CFM)
' ryryry555 r� file�nmi fth1s pen /�
r /CeO A � //Op' ♦/-.S��wj AIR HANDLING UNIT(OVER IO,COII CFM)
S-i ure of A�pphccaannWonImeI& /6/ -L/s GUWe J EXRAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO IOOAOII BTU) Data Receipt#
Will the applicant in future building occupant state or handle heuudous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cada Section 25572(a)T
ElYea 13 No VENTILATION FAN(SINGLE RESID)
❑
ISSUANCE DATE
rg, WilltheapPli<antorfuwmbuilding occupant use equipmenmNeviceswhicb emit BOILP.R-COMP(tIIP OR IWW
, O BTU) 1� pp
hazardous sic conmminmrs m defined by the Bay Am Au Qualify Management BOILP.R.COMP(GVfiR 100.000 BTU) • #'V D
Disfricl?
❑Yea ❑No NEW RESIDENTIAL MECII. SQ.FF.
1 have read the hazardous materials requircmeat.under Chapter 6.95 of the APR
California Health&Safety Cade,Sections 25505,25577 and 25534. 1 understand that 1 1993 ,
if the building does nm currently have a tenant„that it is in,reapomibiliy to notify the C11 r tar
oempent or the requirements which must x met prier m issuance of a Certificate or (;UF'tH IY
aap.ney.
Owner or amhnriuJ agora Date TOTAL: ISSUED BY:
OFFICE
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GeoStrategles Inc. REMEDIATION SYSTEM INSTALLATION PROJECT PLATE
UNOCAL Service Station #5428
10490 DeAnza Boulevard
Cupertino, California ��
JOB NUMBER RENEWED BY DATE REVISED DATE `jha
782806 3-30-93 •''
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REMEDIATION SYSTEM INSTALLATION PROJECT PLATE 4.
G GeoStrategfes Ine. UNOCAL Service Station #5428
10490 DeAnza Boulevard
" Cupertino, California ;
JOB NUMBER REVIEWED BY DATE REVISED DATE
782806 2-8-93