24917 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINOBUILDING.-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, t n ^ (�
BUILDING PROJEC'PIDENIIF'ICATION L 4 J
17
BUL ESS: SANITARY,0. APPLICATION SUBMITTAL DATE'
DUNrr# LO 7„ z�j - 3
OWNERSN ME:
PHONE CONTRACTOR'S NAME: LIC NO: J
NIC CONTROL#
ARCI{I'fECT/ENGINEER: LIC NO: ADDRESS: Ipf
�
CONTACT: NG f,C� PERMIT INFO
,� I QTY. ELECTRIC PERMIT FEE BUILDING
BLDG ELECT PLUMB MF.CH
PIiRMII'ISSUANCE
LICENSED CONTRACTOR'S DECIAR ION APPLIANCES-REMDENTIAL
Metz I herebyamrmthat l am licenmdunderpfovisions ofC and 9(commcnciagwith \ IDH ULSCRIPTION
�O falltEne.ru (fDivi.ion3 of the Business and Pro ionsC�art>f my�;ccnse is in UP PANELS0200 AMPS
F Z ly Liccn.ce Class Lir.# //pp�� //11
'<c. Dat Conme<mr .q 201-RIM AMPSis
5Q IT FLOOR AREA 5/SQ.FT.
FrnZ ARCHITECTS DECLARATION OVER 1000 AMPS
z c) s_ I understand my plans shall he used as public record.
O%—O
F:,rn F-tu SIGNS ELECTRICAL 17
< _J Licensed Professional
W=W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOp V I hereby affirm that I am exempt from the Contmmnrs License Law for the
f+131+.y following reason.(Section]031.S,Businessunit Prafessiotn Cade:Any city or county TE MR METER OR POLE I NS'1.
which requires a permit to conshurt,.1m,improve demolish or repair any awmure .00
prior to its issuance,alsorequimmi
s the aMlicam for such pert to filcasigned summent POWER DEVICES
WC G Oz that he is licensed pursuant to the provisions of the Convector's License law(Chapter
oLL ](commencing with section](kIU)of Division Jofthe 9usincss and Professions Cade) SWIMMING POOL ELECTRIC VV LUAT1p
n ,hill helersempt thewfmmund t classis fnnheullegedexemption.Any violation of
I—ZQ Section 7031.5 by any applicant l'or a permit subjects the applicanuoucivilpenaltyof OUTLETS-S 'CITE ES L/U
CFSnot more than five hundred dollars(E500). STORIES TYPE CONS'IRUCIION
I,mownerofthe n NEW RESIDENTIAL ECTR .t
y3o ❑ props y,e is not ended withwegesaethei(Ser. 044'B .union,
� willdode,sumhe k,amdmeswcwmismrs Lienserawdcaffered arcale(See.]04a,memeros
ane Pmfcesions talo The Conuucmr's License Law doer not apply m un owner of
progeny who buildsorimproveshemon,andwhoich work himedfor throughhis
ovar
employttro
s.pvidedthat succrnt
h improvemsumand arenotimendedoroffered forsalc.If, OCC.GROUT' RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOT
builder will have the burden nr proving that he did not build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE ROODZONH APN
❑ I.asownesofihepmpeny,omexclusivelyconvctingwitbliemn contactorsto
consumer the project(Sec.7044.Business and Professions CW,:)The Contactors
License Law does not apply loan ownerofproperty whobuildsorimproves thereon.and PERMIT ISSUANCE, S
who convects Gorsuch projects with a commit lit hernsed pursuant to the Cumochas CI'ER DRAIN
- &VENT WA
- TER FA
License law. Af ) FEE SUMMARY
❑ I am exempt under Sec. .B&P C for this museumOUTSIDE FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dam DRNNS-FLOORROOF,AREA. RECEIPT p
,
WORKMAN COMPENSATION DECLARATION SCHOOLCORD.
'1'A% Y N
❑ I hereby affirm that l have acenificateofconscnuoself-insure,ora cert -
ificam of "2 FI%TURFS-PER TRAP oo RECEIPfp
Workers Compensation Insurance or acertW iOcopy Ncreof(Sce.3800.Lab CJ which
cove J VV PARK FEE Y N
a all employee's under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT b
Policy# BUILDING DIVISION FEES
Company GAS-EA,SYS'I'I:M-OVER 4(1?A) PLANCHECK FM,
❑ Cenificicopyi,formbyfumished.
❑ Certified copy is filed with the city inspection division. GREASFgNDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMFI[ON FROM WORKERSGRP.ASETRAP SOILS FEE
COMPENSATION INSURANCE
(This cccmmmied not be completed Rife permit is(crone hundreddullars(SIM) SEWER-SANITARY-STORM EA.200ET'. ENERGY FEE
or leas.)
I cerify,lim m duo yys of the wilk far which this permit is issued,Is hall1QT
WATER HEATER W/VENT/F:LECTR
em", la..w in y5tnnn t became s h t the Workers PAID
Compcn. i - o Daer sn t WATT,SYSIENI TREAT ING Dale Receipt#
Q z Applicant
Z O NOTICE.TO APPLICANT f.. tar making this Cenificae of Exemption.you shouldNEWRESIDENTIALPLMB. SQ.FT. TOTAL:
Hrq fornwithc comply
the FVC ar'1Camns orilds permit
heeLabor resolved.
moat
forthwith comply with such pnrvieinn.c onbie pmnit shall M1c deemed revoked. BUILDING hlili
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE: IV V
I hereby affirm that there is o construction lending agency for the performance of
U 0 the work far which this t la i asmed(Sce.3099,Civ.C.) TOTAL: 3 00 ELECTRIC FEE
perms
Lender's Name
0 Lender's Address . MECHANICAL PERMIT FEE PLUMBING FEE �p
U 1 certify that I have read this application and sum that the above information is MECHANICAL FEE '
�-' W sorest. lugreemenmply with all city anJ ttmmy ordinances and state laws relmiri PERMIT ISSUANCE
CL.
building construction.and hereby uulapu�"-=
of this city to enter upon CONSTRUCTION'1'AN
U Z above-mentioned progeny for inspection AhTIiR OR ADO TO MECii.
agreedemnify ae Ciry of Cupertino againu
iesWiuf
jcots costs anderway accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
itberunting thi
AIR HANDLING UNIT(OVER 10,000 CIM)
licanUCommct Dau G%1{DUST GOOD(W/DUCp PAID
I IAZARDOUS ATP.RIALS DISCLOSURE HEATING UNIT(TO 100,60DID'U) Date Recelpt#
Will the applicont or future building occupant store or handle hatumus material HEATING UNIT(OVER Iq)'oq BTU) TOTAL �J V
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Ifi alth and Safety
Coale.Section 25532(1)? VENTILATION FAN(SINGLE RESID)
❑Yex ❑No
-- ISSUANCE DATE
Willmhe applicanmrfuwrcbuildingoccupam useequipmenmrdeviceswhichemil BOILER-COMP(314PORIMMOBTU) A
sounders air examamiamu as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER IM."BTU) W
Diarist', 1199 QQ
Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. MAR ^9 1993
I have read the hexardoaa materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 255]4. 1 understand that
if the building does not curen0y have a tenant.that it is my responsibility on notify the CII I Ur uurCN 114U t
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy. ,^
4
Owner m amhorixed agent Date TOTAL: ISSUED BY: Y`v�
OFFICE