24691 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'19N0BTILUI G-RLKCI RICAL PERMH NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-.MECHANICAL n q C(�
BUILDING PROJECT'MEN'I'IFICAI ION G 4 v J
BUILDING AIIDRESS:G G SANI'T'ARY NO. APPLICATION SUBMI'ITAL HATE
UNIT# LOT# t �
WNIiRg NAME: PHONE: CNTRACTOR' Mli:kIL %M LIC NO:
01 JL5 9'-, {% p O7NIC CON ROL#
ARCH 'IECOENGINHER: LIC NO: - ADDRESS: 5-T Pill �
Z � _
,K19 Y ❑
CONTACT: PHONE:
QTY. FLFCTRICPF.RMIT FEE BUILDING PERMIT INFO
- " BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ED El ❑ 1*
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RE.SIDENTIAI.
Qwz Ihembyeffirmthdl lam licence)unJerpnrvisionxnf Ch.pmr9(convncncingwhh TOB DESCRIPTION
uF100 fall moamd of DivisionJofh B and Cole,and mylicense is PANELS
full fmw.nA elTe/�
"Z,ly Licet �aLc`.Ness en Up TO 200 AMPS
rFi,7y Dme (� Commc ,T¢ lO
ZO�Z7 ARCHITECTS DECLARATION •--'� OVER 1301-IIN00 AMPS AMPS$ SQ.IT.FLOOR AREA M.FU
l unders,.ad my plans shall be used as pablic records.
SIGNS ELECTRICAL -,
Licensed Pr afir,dmnnl
pLL�� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC,
X00. 1 hand,affirm that I am exempt(fans the Cmnmcmes License Law far the
WBWra following reaan.(Semina 7031.50 Bminassmm Professions Code:Anycityme—my TEMP.METER OR POLE INS'I'.
which requires a pemtit to construct,alcor,improve,demolish,or repair any structure
>$ prior,.its ia.anca.aHm re res the licaat forsuch nn file.signedstatement POWER DEVICES
9to PP pcmti
cu". L the ho is licensed plmction7the provisions isinf the Gmwemrs and
Lew(Chapter
�XOLL' 9(nammencingwith Semimn]IKIO)of Division3of the Business and Prnlessions Code? SWI _nNB Il1,0E CIfRFT111C aT VALUATION
W_y or that he is exempuhercGom unJ N<hsis for the alleged exemption.Any vio..tiono,
yZQ Soctinn 7dtl shy any uPFliwm forapermitxohjoctsab,appllcummneivilpmnityof O1 b,. 5=SWITCRIFS- FIX'TUR-ES
�—y0 not more than five hundred dollars(1500). - ,,LL
=mm C C31.asownernOhepropeny,ormyemployeeswithwagesastheirsolecompens.tion, NE ISIDF.NTIAJ.BLLLgR ut, I STORIES TYPECONSTRUCTION
y3Loo will Jo the work,and,hadmicmro sant mandedmoffenal Inrsnle(Sea7(W4,Ha6m,s
and Pmfcssinna Cede:The Contractors License Law does not apply to an owner of I DATE
property,who buildscar impoves thereon,and who mous aeh work himselfim though his
own ctnployoc.s,prmvidel11ml,mis iar,ovememswe nalintendedmidlened mrsale.If, — - OCC.GROUP RES,UMTS
however,the building or improvement issald within oneyearmcompletion,the owner- TOTAL:
builder will have the burden of proving that he Alit not build or improve for purpose of
sale.).
❑ I,as owneraf,he propedy.amexclusivelycomrening with licensed conwctnrsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business unit Professions Code:)'Lha Comrum A -
Licen,a Law does nolmpplyto unownernfpm,,ly who Noldv or improves thereon,aad PURMI r ISSUANCE
Lwxfor sucnpmjectawimmnhan
enrts)licenced p........
e Cammemrx
License Law. ALTER-DRAIN&VENT-WATER(EA) rE SUMMARY
License -
❑ I am exempt under Sea ,B&P C Ins this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner - Dam RF.CEIPTp
DRAINS-FLOOR,ROOF,AIt IiA,COND.
WORKMAN COMPIiNSATIONed to ARATION SCHOOLTAX Y N
❑ IMrehyafrinn then lhave uun;Bcouramnac there f ac.39ly Lm ifiate of REClill'fp
Wnrkcrs'Com FIXTURES-PER TRAP
Ernaatimn lnsuhis I;B mnl[i,A copytheren[(Sec.3B00,Ixh Cd whish PARK II?E Y N
vers.11 ampl1er� this pe L GAS-P RECIi1PT#
q° �� �'3 A.SYST IiM-1 INCA OUI'LFffS
PolicyN ai - BUILDING[)]VISION FEES
Company :M Iia GAS-I:A.SYSTEM-OVERal PLANCIIECKITE
❑ (.edified copy I.hereby famished.
•\!o'/Cenifled copy is filed with the city inspection division. GREASFpNUUSTRL WASTE INTERCEPTOR GRADING PER
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASE TRAP SOILS ITE
COMPENSATION INSURANCE _
(Lit,se,alonnead not he completed ifthepmol,is forms,hundreld.11m,(E lfm) SEWER-SANITARY-STORM FA.20(RT. EERGY ItEl,
males..)
I cenifymm indict petfodmace nfihe workfar which,his permit is issued.I shall WATER HEATER W/VF.NT/F.LECfR
nm, employ any person in any,.Unna so as to hectare subject m the Worker,' PAID
Cmmpens.tinn l,ot,mCid am;m Data WATER SYSTEM/ EATING Dam Receipt N
C) zApplicant
zg NOTICE'IT)APPLICANT:If.mm,making this C,nlGcom of Exemptan.you should NEW RESIDENTIAL PLMB. SQ,LeI'. TOTAL:
bec,mm subject 1.the Wail Compensation provision of the Labor Cade,you mus, -
� ; forthwith comply with such provisions orchis permit shall be deemed revoked. BUILDING FEE
CONSTRUCI ION LENDING AGENCY - - SEISMIC FEE
V z I hereby affirm that is a construction etion lending agency fahe perfomance of
the work far which,Lis permit is issued(Sar.3(11 Civ.C.) TOTAL: RLECI;RIC FIJI
Lenders Name PLUMBING FEE
Address Q'rY. MECHANICAL PERM IT FEE
U I,edify that 1 have mad this application and saute that the above infomralion is
corteet la mwmvmm 1 ,baRrit ndmum Ninmces anti seam laws mlmin ,m PERMIT ISSUANCE. MECHANICAL FEE
V7 r Pywi Ya Yo 8 I
handingatimmal mBad herebypectio Pa naesmhnivesnfthiscityanenterupon the CONSIRUCIONTAX
L) z above-men,inned prnpenyfor emnify,iad purposes. ALTIiR OR ADDT0 MECH.
(We)agree c ave,and a.indemnify and keep harackmayf,a,the City of Cupe,tl,ai t,against
incon lequnce of the
sing expenses which may 111 anyway ncaue.gain,.suiA City AIR HANDLING UNIT rf0 IQ000 CFM)
in consequence of the greening of this pennies
_ AIR HANDLING UNIT(OVER IO,00)CFM)
Signature M Applica t/Contactor Dale EXHAUST'IIOOD(W/DUCT) PAID
I IAZARDOUS MATERIALS DISCLOSURE I[EATING UNI'P(TO 100,000 HT1!) Dut< Rcccipt N
Will the applicant or future building occupant store or handle hvardous material - HEATING UNIT(OVER 100,(X)0 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Ileahh and Safety
Code,Section 25532(a)9 VENTILATION PAN(SINGLE RESID)
❑Yea �}o
✓ ROLLER-COMP CHP OR 100,000 BTI]) ISSUANCE DATE
Will air
applicant minant as building by Ire ay equipment .alit Manaas gement T p ' D
Dikino u,air conuminab as define)by,he Bay Arca Air Quality Management BOILER-COMP(OVER 100,0071 BTU) Ir W
Dis in?
❑Yes , Jct IVa NEW RESIDENTIAL MECH. SQ.IT. JAN 26 1993
I have read he hazardous materials rendretnoats trdcr Chapter 6.95 of the
Ci lifnmia Health&Safety Coda.Sections 25505,25533 it 25534.1 undets moi the
;f the building does nm currently have isa...L that it is my respomibili,yto dandify me CI)T Vr GUren I INV
occupant of Ate nalai mines,which must Is,met prior to issuance of a Car ificm,or
,mpamar.� 01.L�e�_\1K1_ �r•�t�� a'�
Own or awhnnze,l.got - Dlc - TOTAL: d4D ISSUEDBY:
OFFICE