28179 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOx BAINc:-RLPICTRICAL PHRMITNO.
APPLICATION/PERMIT PLUMB Z;-MECHANICAL n p q '7(I
BUILDING nlVlstON BUILDINGPROJECi WENHFICATIOry 201 / J
BUILDING ADDRESS: R /A� SANITARY NO. /APPLICATION SUBMITTAL DATI?
77;_3 5SE8 ^Z 1- ( ONTO LOT IT ( _ 1 �Tq
OWNEI2SN Ijr 7 1 PHONE: C# CI'OR'S NA F: LIC NO:. �O `
�LI1 rp�Y/ Ley [T/ T N/C CONTROL
ANCHITIiCI'/FNGINEIiR: LIC NO: DD is, 7/iV/ �•V .
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT PUMB MECHPERMIT ISSUANCE
LICENSED COM'RACfOR'S DECLARATION pppl,lANCES-RCSIDIiNT]AI.
p y.z, Ihertbyaffirm thmlannlicensW undmprovisinns of Chapmr9(commmcingwith J DESCRIPI
V100 Section force and effort
f Division]0f the Business and Pmfesaions CWe,and my license is in PANELS
��
Fyey� full incrusCla's-fecta� vv
<u License CynsaLiap B UP TO 20E AMPS
rFir�y
Date_(G� Contractor 201-Ifl(IO AMPS
,Z OFyZ ARCHITELTST)CLARA TG OVER 10110AMPS SQ.Mr.FLOOR ARBA $ISQ.M.
O Z—Q1 understand my plans shall be used as public records.
F y f JJ SIGNS ELECTRICAL
qq��JJ J Licensed Professional
5y�4 that
Ima-exempt OWNER-BUILDER the Contractors
SPECIAL GIRGDIT/MI$G.
KOyU 1 hereby affirm that I em exempt Tran the ComonsCode:
'a License Lew for the
followW 34y which oapairaon(man
land Professions Ca or many city summon TEMP.MFI'ER OR PoLL INST.
which requires in permit recnnswe6 aper,improve,demolish,or repair any structure
}� that hei licenance.olso.rorauires the applm,ofor the Copertniuo Rleasigned[.m statement POWER DEVICES
u1 �p thatmisncing d TO with S9ction7he)m'Dilonsnf theContractors Business
License[.me
as z 9(c0mmencin lM1 Section 7000 !Division Sof the Business and Professions Code SWIMMING POOL ELIiCTRIC
�4Mto (commencing )0 ) VALUATION
W❑y or he7031. by tyappmmand the buspermit subjects Thedesemptt to. civiny l
of OUTLITT S-SWITCHES-FIXTURES
f—_Ga not moethnbymndred cant ret$500).tsubjenstheupplicannoacivi]peachyof
<g not more than rive bundmd dollars(SSW). NEW RESIDENTIAL ELECTR _SQ.FT.
W p ❑ I,mnwnendOmpmpedy.ormycmpinyees with wegcaasthcirsa ecnmpensation, STORIES TYPE CONSTRUCTION
4a will do the work..d thestmaure isnot intended or0ffced fortune(See.]04,1,Bus]ness
and Professions Cale:The Contractor's License Law does not apply to an owner or
property who builds or improvestliefcon,and whodrcssuch work himeclfurthroughhis
morremployers,providedthat such improvcmemsam not intended oroffered tarsale.If, OCC.GROUP ERES.UNITS
low ever,the building or improvement is sold within one yearofeompIn loo,the nwaer.
builder will have the burden or that he did not build or improve for f t O
proving P PuePoseO
tale.).
❑ ],wowneronhe properly,nmeulusively am0aaing wifi licensul c0nrtacmrsto QTY. - PLUMBING PERMIT' ITC MOOD ZONEl'N
conson ct the project(Sec.7044,Business and Professions Cale)the Camtacmr's —17
License Lawdoes not apply to an owncrofproperty who builds or improves therm.aM PERMITISSUANCE
whocmmucts for such projcets with a contractors)licensed pursuant to the Contractor's gI:IER-DRAIN&VIiNT-WATER(G)
Li cease Law. PEE SUMMARY
❑ I um eaempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE tL1:S
SANITARY Y N
Owner Date RECF,IPI'tl
• DRAINS.I1.00R,NTF)h,ANIiA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ en Couarfirmth Insurance
ortificateofronsenr to ercuf(insure,0r sem i.)which FIXTURES-PER TRAP RECEIPTN
Workcrs'Compensation lnsumnce 0racenified copy therarf(Sec.JSW,Isb C.)which PARK FRE Y N
coec"rillemploym'e nB erthi• a .t GAS-EA.SYS'IP.M-IIN . O .E RECEIP #
Policy d BUILDING DIVISION FEES
Company • fqq GAS-EA.SYSTHM-OV 4 PLANCHECK FEE
Certified copy is hereby famished.
CenifieJ copy is fled with the city inspection division GRIASFII U ASTE INTERCE I GRADING FEE
CERT IFICAI E OF HAEMIIHON FROM WORKERS' GREASE'! SOILS FEE
COMPENSATION INSURANCE
('This section need not he completed ifihe permit is for one hundred dollms($I W) SEWER-SANT'A Y-STORMEA.200FT. ENERGY FEE
less)
I cenifymat lathe performanceofthe work for which this permit is issued,I shale WATER BEATER W/VEN ELECTR
not employ any person in any manner vo as In become subject to the WorkersPAID
Compensestiontaesof Califomia. Date WA TER SYSTENUTREATING Date Receipt
C) 0 NOTICE TO APPLICANT If,after making this Certificate of l?semption,you should NEW RES]DEN'I']AL PLMB. SQ,FT. TOTAL:
r-I T/) become subject o the Worker's Compensation Provisions of the labor Code,you must
I� 7 forthwith comply with such provisiton
ns his permit shall lx allocated revoked. BUILDING IEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
-a,- z I hereby affirm that hem is a cmistan tion lending agency fm the rmfortm nce of
U O the work for which this pemnit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Isnder's Name
COU Leaders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify That I have read This application oil into that the above information is
7" comet.I agree to comply with all city and county ordinances end vlatenvas relating to PRRMITISSUANCE M ECI IANICA I.FEE.
building construction,and hereby authorize represented ves ofthis rayto enter upon the CONSTRUCTION TAX
U z above-memioned property for inspection purposes. AIA VR OR ADD TO MECH.
(We)ngrte m save,indemnify and keep harmless the City of Cupertino against
habil Ities,judgments,mstsand eapensas whleh may In any way accrue ii,insTsaid City A I R HANDLING UNIT COO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.0001 CFM)
Signature of Applicant/Contractor Due EXHAUST FOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]]'OTO 100,000 BTU) Uare Receipt#
Will The applicant at future huilding occupant store or handle hazurdom material HEATING UNI'1'(OVER 10!1,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Heahh and Safety
Code,Section 25532(e)?
❑Yes ?�Nn VENTILATION FAN(SINGLE RESID)
Will the applicantor rumrebnildingoccupam useeeluipmem ordeviceswhichemit BOILER-COMP SHP OR 100.0Y)BTU) P'p' 'e��T15v E:DATE
hazafdnus air conterminous m defined by the Bey Area Air Quality Management BOILER-COME(OVER I00,000BTU)
Dietnet? ❑Yea ?""mNEW RESIDENT IAL MECH. JUN 14 1995
SQ.FI'.
1 have mad the hazardous numnal,reyuirements under Chapter 6.95 of the
California Heaph&Safety Code,Sections 25505.25533 and 25534.1 understand that CITY Ur Wi'tHIINU
ifthe building does not currently have a tenant,that it is my responsibility m notify the
wcupnn[of the celmo me is which must be mat prior m n,micur of Ce I I-'to it
'Itai Ps—
Owner tar autboriuJ agent ate ISSUED BY: Vim_
OFFICE