28157 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
It UILDIN0-ELECI'RIC\I, PER?IIT NO.
CITY OFCUPER'CINO APPLICATION/PERMIT rl.wurrNo-\ucH,\Nlc,\L _ 28157
BUILULN�f:UI VISION OUILDhNG 1'RWRLT IUESTIPICATION
BUILUTAG Ap RES$: . f SANHARYNO. WPLICA'DUN
aSUBMITTAL DAP.
U/ / ��G1F<Gg4 > a 11NITp LOT
•.�lN'IER$ \ilE: PHgNE: CONTR ORS NANI': LIC
�c 14eF2)X � '713-4147 Tl0vt �M �/u- flplil$3 NfC CO,NTROLN
xRCHi I hL IlENGINEER: LIC NO: ADDRI' if 3. `1 � y
CONTACT: PHONE ''' T J EE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT . '.-FEE '
(/ �� /•-\,.,v gL ELECT PLUMB AIECH
PERMIT ISSUANCE ^'E� El 1:1 El
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB UFSCftIPI�
z'Z Ihambyaffrm that film 3ofilhnmdunss and
sions Corer and mmeneise with vt _4r
�00 Section 7000)n of DivisionJo(the Business and professions Code.and my license is in PANELS
w[_F-- lull(so C`L �>j �J
IVU n41 C Lic.p s 1—'I�� UP TO'_IXIAMPS
F`m Licenx Clas - t
onz Date Contrem,
201.10011 AMPS SQ.IT.FLOOR AREA $ISQ.FT.
�yZ ARCHITECT'S DECLARATION OVER IOW AMPS
1 undemord my plana shall he used as public records.
OZ = SIGNS ELECTRICAL
Licensed Professional
s�z¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/h115C.
'OaU 1 hereby affirm that 1 am exempt from the Contmdors License Law(or the
'3Qvo following remains.(Section 703 LS.Business and Pro(msions Cade:Any city or comity TEMP-METER OR POLE INST.
Q which requires a permit to construct,alter,improve,demolish,or repair any s recome
,c'y2 prion,its issuance.almrequlrea thenpplicam Initials permiuo file aeigned alinementPOWER DEVICES
Z z Q 0 Ibat he is licemed pursuunno the provisions of the Comnetor's License Law(Chapter
''KoroW 9(commcceing with Section 7(N )of Division 3 of the Business and Pro(essimm Code) SWIMMING POOL ELECTRIC VALUATION
LI-y or that he is exempt therefrom and the lssis for the alleged exemption.Anyviolation of OUTLETS-SWITCIIES-FlXTURES
(-Z> Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
�_� t mom than five hundred dollars 0504y. NEW RESIDENTIALELECTR —SQ,FT. STORIES TYPE CONSIRUCIIO?
E-
Ko ❑ Laxosocrofthe Propeny.ormycmployeeswi[h wages as theirsolecompenxation,
W3" willdothe work.and the s[rucmrtis notimenJNormffereJ forsale(Sec.7614,Business
and Professions Calc:The C,ma.mes License Law dxs not apply m an owner of
pmpertywhobuildsorimproves thereon,mal whodoessuch work hitnselforthrough his OCC GROUP RES.UNITS
n employees,pmvlded that such improvcmemaaenm imendedormffered formic.If,
however,the building or improvement is laid withinone yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of _ _ -
sale.). • ., \.['.('•:' a[ �•S'FEE".''4 _ZONE APN
❑ Lan owner mnbe pmpcnY,amexdusivdy ronmacting wire licensed<omranomo 'PLDMHING PERMIT,' - �.,
z.
construct the project(Sec.7044.Business and Profession Cafe:)The Commnors PERMIT ISSUANCE
License law d«snot apply to an ownerof prnparty who builds or improves there,n.and
whmcommcrfor such projects with a commeams)licensed pursuanu,the Contractors ALTER-DRAIN&VENT-WATER IEAI FEE SUMMARY' ''=%y�""E
License l.aw: -
❑ 1 am exempt amler Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE 'ES
SANITARY YN
RFCEIP a
Owner Date DRAINS-FLOOR.ROOF.AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
I hereby affirm that 1 have a certificate of ennxem to self-insure,or a crnificam of RECEIPT'p
tl%TURFS-PER TRAP PARK FEE Y N
rem
rkers Compensation insurance or a certified copy thereof(Sec.38W.Lab C.)which REC[IPT a
all employee's under this permit.%s 1C,f¢/�[ /,� ¢ GAS-EA.SYSTEM-I INC.J OUTLETS BUILDING DIVISION FEES
icy M k•V y(31st-+f a
party R-` GAS-[A.SYSTGM-OVER4(E\) PLANCHECK FEE
Cmified copy is hereby famished.a
Certified copy is filed with the city inspection division. GREASEJINDUSTHL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This a.unerecd not be completedHire permit is forms,hundred do][.IS1W) SEWER-SANITARY-STORM EA.200FT. I ENERGY RE
or less.)
I certify that inthe performance mf,hewmkforwhich this permit is issued.Imall WATER HEATER W/VENT/ELBCIR
not employ any person in any manner so as in become subject to the Workers' PAID
Cia,vnmn Ww
inndCmifomia. Dine WATER SYSTEM/IREATING Date Receipt
O Z Applicant
z 0 NOTICE TO APPLICANT':If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. QTAL:
= become subject to the Worker's Compensation provisions of[he Labor Code,you must BUILDING FEE
> forthwith comply with such provisim a or this permit shall be deemed revoked.
6L. Q CONSTRUCTION LENDING AGENCY SEISMIC f
z I hereby air,.that there is a consfraction lending agency for the Acro mtwce of TOTAL: ELEMI
V O the work for which this permit is issued(Sec.30O,Civ.C.) -77 ' _ _
Lenders Name "( - T' ' - 't sr6� PLUMBING FEE
Lcndus Address QTY. '`' EC RANI CAL PERMIT
O IJ I certify that I have read this application and nate that he above mumparliest is
MECHANICAL FyE
>" corect.lagme to comply with all city and county ordinances and state laws latng to PE IIT ISSUANCE
building conswction.and hereby mu,man,c a,omp abvc, f,his city to enter uponthe CONSTRUCTION AS
V2 above mentioned property fit,inspenian purrysxs. A R OR ADD TO MECII.
(We)antic to save,indemnity and keep hamlen the City of Cup,nimt aIp imt
lubilitcs,juJgmeals.c,srs and expenses ewhich may in way cmgainst said City ry AR HANDLING UNI Oto,"CFM)
in consequence of the granting of this pewiL. A HANDLING UNIT(OVER 10. Al) '
Sign:nurcnt APPli.uI1Comrmmr Date E, AUSTHOODOV/DUCII PAID
It
HAZARDOUS MATERIALS DISCLOSURE
HE TING UNIT(( 0 I00,1 Dam Receipt
Willthe ap,l,c.r, future building mccupom ms,or handle b.drus material HEA ING UNI OVE IW, BTU) / TOTAI"
as dc•IineJ hY the Cupertino Municipal Cede.CM1UPter 9.12,mJ the Health and Safety
Carle.Section 25532(a) / VENT \TION Si LERESID)
❑YjS
• - �f I Sl{nN[F�ATE
BOILGR- .II RIW,WO TU Jh 1
Will the I applicwuorfmum it fired by she use equipment Quality eswbichemit
haardmm at contaminants m Jifined DY the Buy Area Air Quality Managemem BOILER-CO (OVER I W.IMM)BTU)
District, P// JUN 0 9 1995
Ely ea No NF.W'RFSIDENTIe A1EC11. SQ.1T�.
1 have read the hemardoun materials requirements under Chapter 6.95 of the
Culitumia Hcahh&Safety Code,Secdmmn25505,25533 and 25534. 1 uoJeound that GIJptHliN/l
little building docs not Currently have a Lenank that it is my reaWnsibility m notify the
occupant Iaut�t.unleJa I n.aa ,r a�Cem�r,ate a
rt
mran dagcntO.oeror hDoc
"TU'gAL; ISSUED BY:
nFFICF