24609 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' B ILDING-ELB RI AL PERMIT NO
APPLICATION/PERMIT PLUMBING-MECHANICAL 24609
� O/N
BUILDING DIVISION BUILDING PR0jKCT IDE\ L1'WICAI'ION VM
BUILDING AIT
ADDRESS I(�/ /J /� � � � SANARYNO. APPLICATION SUBMITTAL DATE
3 1 I Ws��--�� UNIT#g55_0& LOT ��
QW ' SNAME: ®j n rf'NONE:_ CONT N M 'CN�� ` ` N/C CONTROLp
•AR ITE(T/F.NGINEER: { LIC NO: ADUKIf&� �J 4 ❑
CO PHONE: JJ
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
47
I r/ l" VV IZJ PERMIT ISSUANCE BLDG ELECT PLUMB MEC
❑ ❑ ❑
LICA SED CONTRACTOR'SDECLARATION gppLIANCES-RESIDENTIAL JOIi ASCRIPTION
C=Z Ihereby affinn that lom licensed under provisions ofChapmr9(commencing with e
00 Seaian)0010 rfD sig Business un ProltsC dcsand mylicenx'u in PANELS
me no
Ufa
erre t. i e J
F,lLL] License Clu.' �l.J Conor IIP TO AMPS
w Q H Uae Contractor 201-1000 AMPS v (�
i ONZ
O Z_ ARCHITECI'SDI' A OVER 1000 AMPS
1 understand my plans shall be uxd as public rewriz. SQ.FT.PLOOR AREA $/SQ.FT.
F h 1=w SIGNS ELECTRICAL
Licensed Prnlcssional
�C1'Q OWNER BUILDER DECLARATION SPECIAL CIRCUCOMISC.
a Oo. 1 harhy affiem that 1 am exempt from the Contractors License Law for the
t'i 3ay following rtasoo.(Section 703 L5,Business and Profusions Code:Any city or county TEMP.METER OR POLE INST.
a0; which requires a Permit m construct,alter,improve,demolish,or repair any nrvervre
}� prior 1.its issrance,alao requires Neapplicant for such pcmtino Glc.afgmdsmtemcnt POWER DEVICES
to m C 0z that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
dk.T 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATI
IA—a ontion731.5hin he is by my applur icant
fthe basis permitfor the nlkgedexemPJan. civiny l plaurnof OUTLETS
F•Z_> Section7031.5by hundred
undre dollfs($50%it subjecu the applicant coacivil penaltyof FIXTURES
(/
not momthan fiveethopro dollars($50%
O NEW kESIDENI'IAL ELECI'R S FT.
E�m ❑ Lthe woaTandthe opeery,ormyempcandedwithwed fierttle(Scle compensation, Q' STORIES TYPE CONSTRUCTION
I
will dotheandthe heComfsaol's License
does not
9044,Business
:tori Pndcsinns Calc:The Contractor's Liccvc Luw docs not apply to an owner of
propenywhobuildsorimprovcsthcmon,andwhrdoes such work himxlfonbrough his -
own employecs,mvided Natsuch Improvemcntsmic not intended reoffered hrrsale.IL OCC.GROUP RES.UNITS
however.the Infringer improvement insold within one year ofcompletion,Nerwner- TOTAL: r
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
El1,asownerOfineproPeny,atm exclusivelymmrvaingwiNlicensed convanonm QTY. PLUMBING PERMIT F r r Z .; ppNt
outsmart the project(Sec.7044,Business and Professions Code:)The Contmetor's
License Law does not a to am owner of proves PERMIT ISSUANCE
apply entions)whosed pane Ncrcrgand IIII V J 0
wM1enseLaw,lorsucM1pmjnYswith anrntm<mrtn)IicenuJ punuuntmthe Contractor's ALTER-
LicenscLaw. DRAIN&VENT-WATER(EA) _':�F$ UMMARY
❑ 1 um exempt under Sec. B&P C far thin reason BACK FLOW PROTECT.DEVICE L )FBI.
Owner Dec. SANITARY ry
DRAINS-FLOOR.ROOF,AREA.CONE. RECEIPTn
• WORKMAN COMPENSATION DE LT.ARATION "IBAII.TAX Y N
Ibereby.ffirmnion that ihave
mance or ifcat hd comm�tanxlf-imsure,n.Lab C.)which
FIXTURES-PER TRAP RECEIPT#
orkcrs'Compensatinn lnsurvncc oraanificdc the rof(Sc00,fabCJwhfcb PARK II:E yN
eovers.11empl er 1^=�' �y�/ i GAS-EA.SYSTEM-1 INC.40UTL8TS RF,CF.IPTM
Policy vV{' Gil BUILDING DIVISION FEES
Comp GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
enfficd ropy is he by famished.
enifiee copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATEOF EXEMPIION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed True Permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT,
or less.) ENERGY FEE
I cenify that in the performance of Ne work for which this permit is issued,Ishall WATER HEATER W/VFN ELECTR
oat employ any person in any manner so as to become subject nt the Worker' PAID
z Compcnsatinnlawsol Califrmio. Date WATER SYSTEM/IREATING pate Recciptp
O Applicant
z0 NOTICE 1'0 APPLICANT:IL after making this Cenfficme of Exemption,you should NEW RESIDENTIAL PLMB, SQ.FT. TOTAL
E"' % become subject to the Workers Compensation provisions ofthe labor Code.you must
fnnhwith comply with ouch provnions orthe,permit shall bn deemed revoked. BUILDING FEE
Q. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
=i z I hereby affirm that them is a construction lending agency fur the perfommnee of
U O the work for which this permit is issued(Sec.301 Civ.C.) TOTAL: ELECTRIC FEB
U. ti Lender's Name
O U tenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W I certify that 1 have read this application and Stam that the above information is
FR. coned I agree In comply with all city and county ordinances and state laws mlmingto PERMIT ISSUANCE MECHANICAL FEE
building consuumine,and hereby authorize represemmivesof Niscity m emerupun the I CONSTRUCTIONTAX
V z adrve-mentioned pro for inspcmfrn puryous. ALTER OR ADD TO E10,�
(We)agreew Icin tnJ keep hurmlcns the Ciry ofCucnioo ugninxtliabilaiesJudgmen c .s dexpen. hichmayinanyway accrvca��Id City AIR HANDLING UNI )in eom,alneer th ng is permit. / AIR HANDLING UNIFM)Signature orppplumen/ dor Et]
Dole EXHAUSTHOOD(W/ PAID
HAZARDOUS MATERIALS DISCLOSURE t{BATING UNIT(TO 1Date RaeiptN
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety BEATING UNIT(OVER I00.00O BTU) TOTAL:
Code.Section 25532(a)P
El Yea 0N VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 1IX000O BTU) R'1SSUAf(f)DATE
Willtair coternncifuture building by the ay ArcoAen Qualit Man igemeit gg'"' /3yC 11 �J
• hmmdom ah contaminants as defined by the Bay qtw pie Qualiry Management BOILER-COMP(OVF.R PA1.001 BTU)
District'!
❑Yes ❑No NEW RESIDENTIAL MECII, SQ. T. OCT 25 1993
I have rete the hay ohnisCade.materials requirements unser Chapter understand
of the GIIY ur JJ
California ldogdh&Safety Cade.Sectorsons25505,t it is my responural 25534.sibility
1itytontif ohm _ LurtKjll�(�
ifcuant oftencsnotments yhaveast b m,Natitis myssuanc of
tenotify the ..
occupant of the requirements which must be ma prior m issuance of a Certificate of
Oea:pancy.
Owner rr au hmi,ed agent Date TOTAL: ISSUED BY:
OFFICE