24789 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECRICAI- PERMII'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBBSG-MECHANICAL ^ O
BUMPING PROJECTIDENT1111CA'f10N ' 4F O
BUILDINGADDRESS: �_���� -70 LV s LOTM SANITARY NO. APPLICATION SUBMI'19'AL DATE
4PS
OWNI' NAME: .�� PBONE: COIj'U"01OR'SNAMC: LICNQ:�� la
P / V� F ao� 3 N/C ONTROLp
�ARCHU'ECT/PNGINEFR: LIC NO: DR' S: J
b W o R 2
CONTACT: ]'DONE!: QE.y. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PI?RMI'1ISSUANCE El El El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL sP' r` SCRIY.NO➢ixwm
Matz I hereby affirm that l smliccnsed underpmvisionsofChapmr9(commencing with f„/Y-e-P
0000 Section?000)ofDivision 3ofthe Business.11ProfessionsCode.and.1license isin PANELS
FQU6 furl mane onaerR D3S"QQ 5'�jptt/(;t��S IO COA�
Licc . -n29 Contractor 3T� (._ UPT0200AMPS
ro?y Uam Comrazror—y.�`OIJQ 201.1000 AMPS
Z OyZ ARCHITECTS DECLARATION OVER 30011 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—O 1 understand mnsy plashall be used as public records.
�mFW SIGNS ELECTRICAL
Licensed Professional
i�16U OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Nita.
1 hereby affirm that I am exempt from the Contractors License Lew for the
W3f-w following..on.(Section?031.5,Business and Profusions Coda Any city m coumy TEMP.METER OR POLE INST.
�ta'wJ which requires.permit to amobacl,a)mB improve,demolish,m mpaif any structure
ty
q Y2 priono its issuance,also requite n
the applicant far such permig file a signed statement POWER DEVICES
R(C G 0mat he is licensed punuenr ro rhe provisions of me Commaoh Licenm Law(Chaplet
aSo� 9(commen<ing with Seaion]0000 ofDivision3ofthe Busirress end Pmfeuinna Ede) SWIMMING POOL PLECIRIC If;60
VALUATION
�^y or Section
7031. by mpt
mfromand r.Permit subjects
theJp,lica exemption. civiny l
of OUTLETS-SWITCUES-FIXTURIS
FRQ Section than
by ive hundred
undre dollars
subjects the upplicennnecivil penalty of
E20 n i,ascan rofhe rndny,lor yempl NBWRFSIDENDALELECTR _SQ.FT. STORIES TYPECONSTRUCf10N
ap,'FD ❑ othe wrk.afinepeopaciumimyeivpinyeawimweguutheinole7044.Bsiness
3=a will do the the ra Cmuianmimm�Jedorn.this,cont apply bD41,Bmineof
end ProfesheW Cade:The vasdawmrs ndwhe law does nm apply lf an owner of
propemploy buildeared that esrhimpro ermals Joessucneaded imselr.n throughhis OCC.GROUP RES,UNITS
n err,the bs,providri that improvement
Iss sold
wit erenotyew ofJmofRm1 farsole.owner.
h Wever ill hav l the burden ofpment is sat he didn one yeat or improve for perthe seof TOTAL:
builder will have the burden of proving mor he did not buil)or improve for purpose of
ale.).
❑ Les ownernfthe property,amexclusivdycontracting with licensed contractors to QI;Y. PLUMBING PERMIT FF,fc F!ODD ZONE APN
construct the project(Sea 7044,Business and Professions Cale:)The Comiantnf's
License Lawdoes notapply to an ownerofpropeny who builds in improvesthereon,and PERMIT ISSUANCE
whoco erects fnrsuch projects with a contrachmad licensed pursuant a the Convectors
Lire.¢Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am<xempt under Sea ,B&P C rnr this reason OUTS DE PEES
BACK FLOW PROfLCI'.DEVICE SANITARY Y N
Owner Dam RECEIP #
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARIiA,COND. SCHOOLTAX YN
I hereby affirm that l have a cerificem ofennsem to self-insom orocenificamof FIX'F)RES-PER TRAP RECEIPNI
Xrkm Compensutionlnsumneeorecertifedcopythemof(Sec.3if),l.abCJwhich PARK FEE Y N
coven all employeds under this permit e'1/ bpI / —�L'� GAS-hA.SYSTEM-I INC. 0UTLEfS RECEIPTN
POIIayN- d Y 7(0 f0 BUILDING DIVISION PEES
Coact ' GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished, -
Certifiedcopyisfiledwiththecityinspectiondivision, GREAS1?✓INDUSTRL WAS'IEINTERCM. OR GRADING FEE '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASBTRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nm be completed it the permit is for one limobadd.1hos Li RNLI - SEWER-SANITARY-STORM EA.200FTENERGY FEE
or las.)
I cerlfy that in the per4memea of the work for%blell Ods lmnnir is issued,l shall WATER IIEA'I'ER WNPNI 0.EC'11R -
nm employ any person in any ms to,as m m m
become.ahjcct e Worker' PAID '
z Cnmpensvtion Laws of C�.lifnmio.
Data WA SYS'T'EM/TREATING - Dem .Reeeiptk
C) Applicant
z C NOTICETO APPLICANT:If,ul'o,owking this Ccrtifctmof Esenption,you should NEWRESIDEN'1'IAh('LMP. SQ,IT. TOTAL:
p] becameeubjccnume Workcr's Campenentinn provisions of the Lwor Cala,you must
fnnhwirh comply with such prnvisimm o,this permit shall be dmmud revoked, BUILDING PER a I
H •7
OWr A CONS'I'RUCI'ION LENDING AGENCY SEISMIC HE i
z I hereby affirm that there is a construction lending agency for the lwrfonnunce of
U O the work for which this Permit is issued(See.3007,Civ.C.) TOTAL: ELECTRIC FEE
fender's Name
O U lender's Address - qrY. MFCUANICAL PERMIT FEF PLUMBING HE
1 eci ify that 1 have read this eppliewimn turd slam that the above infummtion is
correct.I agree In comply with all city and county ordinances and state lawe tittering to PERMIT ISSUANCE MECHANICAL FEE
rbuildingwnstruction,and hereby authorize representatives ofmis city roamer upon the - CONSTRUCTION TAX
J 7-. above-mentioned ms
ove-mentied property for inspection pwpo , ALI I?R OR ADD 9'0 MECII.
(We)agree to save,indemnify and keep harmless the City of Cupmrtinu.agninst
habiliries,judgmema.custs and expenses which may in any way acerecagaloo said City AIR HANDLING UNITO010,(100 CFM)
in consequence of the granting of this permit
AIR HANDLING UNIT(OVER 10/000 CFM)
Sign store of Applawal/Cantrecror Data EXIIAUST GOOD(W/DUCT) q
PAID
HAZARDOUS MATERIALS DISCLOSURE 11[iATING UNIT I'1'0100,(g10BTU) Data Receiptp
Will the applicant or future building occupant More or handle haardons material FlEATING UNIT LOVER 100,000 BTU) TOTAL:
as definW by the Cupertino Municipal Cndc,Chapter 9.12,and the Ilulth and Safety
Cade,Section 25532(n)?
EI Yes CI No VENT ILATION PAN(SINGLE RESID)
Will meeppliunr or fmurebuilding occupant use equipmenmrdeviceswhich emit
BOILER-COMP OUP OR 100,000 RTU) ISSUANCE DATE
harmJous air comaninwb a defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) 2�e+ �
Down.? 7
❑Yu ❑Nn NEW RC•SIDIiNT1AL MECII. SQ.FT.
1 have read the hevrdous materials requimmems under Chapter 6.95 of the MAR.121993
Califomla 1lealth&SafetyCale,Sections 25505,25533 and 25534.1 undersand that
ifthe building does not currently have aactual,Nal it is my msponsibilitymnmify the CITY �1 b
occupant of the requir men¢which must bat mer poor to issuatme of a C<nificate of C(L Y V I� I/urtf3l IND
Occupancy.
Owner m icithorized egem Dam TOTAL: ISSUED BY:
OFFICE