26497APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOroll" N" -EI"
BUILDING DIVISION APPLICATION/PERMIT PLUMBI-MECHANICAL
BUILDING PROJECT IDENI'DILATION
PERMIT NO.
26497
BUILDING AOOREESSS: s�(J C (.1 Q'.I ./
`� 1063 Cl4Qi S"rEtU C.��N N.T.U1y OTN
SANITARY NO.
APPLICATIONSUBMITTALDATE
�—�a
OWNERS NAME: �� 1 Va L
CONT DR'S NAME: LIC NO: N
lWls
N/C
,CONTROL#
ARCHITE.0 (ENGINEER: LIC NO:
ADDRESS:
��� 3
CONTACT: PHONE:-
"' cr - •` -
QTaY.,LSELE�CFRIC PERMIT FEE
UILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'SunclmDECLARATION
I hereby affirm thetlunlicenud underpmvisions nfChepter9 (commencing wit
Section sfalb Of Divisio 3 of the Business and Professions CCodee caul my license is in
nsefarClad cffect/asol1, 569 'I -U3
Licfullense
Date Class [ISS V ContPrract
Data Ganunctm
pppLIANCFS-RPSmENT1AL
'rIJi1r vsrrtat ,�a��
j 1V;�j' VfMisa-1 "Basi
s�
ppNEtg
I UPT0200AMPS �'�
201-IOODAMPS
ARCHITECTS DECLARATION
I understand my plans shall he used o public records.
OVER 1000 AMPS
SQ. FT. FLUOR AREA
RARE
s a a
t a
I_ TI�.(
i E Y
n
Y
.PT.
SIGNS ELECTRICAL r
Littnsed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Nat I not exempt from Ne Canaecmra License Law for the
tion 7031.5, Business al Professions Code: y city or county
following reason. (SecuAn
which requires a permit to construct. Ater, improve, demolish, or repair any sanctum
prior to its issuance, Asa requires the applicam for such permit to file a signed statement
that he is licensed pursuant to Ne provisions of the Connectors Licanae Lew (Chapter
9(commencing with Section 7000) ofDivision 3 ofthe Business and Professions Code)
or that he is exempt therefrom and the basis fmthe alleged exemption. Any vioHtioa of
Section 7031.5 by any applicant for a permit subjects subjects the applicant to a civil penalty of
nor mothan live hundred dollars ($501). ❑ re I,mownerOhhe Mm ay,ormyemployc.widtwag.otheirsolecoapensadon,
wit] do the work, and the suuclum is not intended Or offered fm sale (Sm. 7 f) EL Business
and Professions Code: The Contractors License Lew does not apply to an owner of
property who builds orimprov.thereon, and whodaen such work himselfor through his
own employees, provided that such improvements art not intended or offered for sale. If,
however, the buildingor improvement is sold withinonm yearofcompletion,the owner -
builder will have the burden ofpmving that he did not build or improve for purpose of
vale.).
❑ Las ownerofthe propenmy.aexcloivelycontracting with licensedco muctoom
construct the project (Sm. 7044, Business arhd ProfeaAans Code:) The Contuctore
License Law does not apply to an ownerufpropeay who builds err improv. thereon, and
who contracts for such projects wit a contracmr(s) licensed pursuant mthe Conuac[aes
License Law.
❑ I mn.empt under Sec. , B & P C for this reason
SPECIAL CIRCUTf/MISC, IIt rte,
TEMP. METER OR POLE MST. Q'�
u w
POWER DEVICES I
SWIMMING POOL ELECTRIC qTE
ALI IN
OUTLETS - SWITCTTPS- FU(TlIRES
NEW RESIDENTIAL ELECTR _ SQ. FT.
STORIES
TYPECONSTRUC ION
OCC GROUP
NES.GNITS
QTY: j " jPLUMBING PERMIT FEE
MOOD ZONE
APN
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATCR (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
O
SANITARY Y N
RECF.IPTN
Owner Data
DRAINS -FLOOR, ROOP,A OND.
WORKMAN COMPENSATION DECLARATION
❑ [hereby affirm that l have a certificate ofconxem to self-insure,mettmficrnaa
Woheri Compensation lwu.ntt meartiRMcopy Nercof(Sa.39K,LMa CJ which
covers all employee's under Nis pemtit
Policy p
SCHOOLTAX YN
RECEIPTp
FIXTURES- PER TRAP
PARK FEE Y N
RECEIPT N
GAS - EA. SYSTEM-] INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
❑ Cenifledcopyishertbyfumished.
❑ Cooped copy is filed with the city inspectiondivision.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION MSURANCE
(This section need soothe coaplecal if Ne permit is fmmre hundred dollars($IDE
less.)
[certify that in the perfomtesoce of Ne work for which this pemdt is issued, Ishall
non, employ any person in any marmm so az m become subject or the Workers
Compensation Lawsof Culifoaia. Date
Applicant
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
GREASETRAP
SOILS FEE
SEWER - SANITARY - STORM IBA. 2WFT.
ENERGY FEE
WATER HEATER W/VENT/ELECTR
WATER SYSTENU REATING
PAID
Data Receipt
NOTICE TO APPLICANT: If, Ater meting this Cmifiateof Exemption, You should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such Provisions or this permit shall be demand revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affims that there is a construction lending agency for the perfmmantt of
Ne work for which this parm l is issued (Sec. 3097, Civ. C.)
Lenders Name
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
BUILDING FEF.
SEISMIC FEE
as
ELECTRIC FEE
PLUMBING FEE
MECHANICAL. FEE
QTY. " =. MECHANICAL PERMIT FEE
" I
Lenders Address
I ttrtify that I have rem! this eppli.0on and More that the above information is
correct. l agree no comply with all city and county ordinances and state laws relating to
building construction, and hereby anNoriu representatives of this city m enter upon the
above-mentioned property fm inspection purpose.
(We) agree no save, indemnify and keep humless the City f Cupcnina against
Iiabiliti.,jmigmen costsaodexpenseswhi nanyway rueagainsuald Ciry
in consequence gmnfin Of I
rKpp—IA Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building cocupent store or handle: hssumbna material
o defined by the Cupertino Municipal Cale. Chapter 9. 12, and the Health and Safety
Code, Semi ElV. C3 No 25532(e)7
❑
Wusair conareaments as defined ,Bay equipment ualityc Managementtroul
heardaus air comamiwnta o dcfned by the Bay Area Air Quality Manngement
by
DiMncQ
❑Y<e 0 N
1 have read the huallous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand thu
Him building does not currently have o mount. that it is my responsibility to runty the
O ccuupanc pas of the requiremema which must he met prior m issuance of a CrniOam of
Occupancy.
cy.
t PERMITISSUANCE
ALTER OR ADD TO MECH.
CONS TRUCf10N TAX
AIR HANDLING UNIT(TO IO,OW CFM)
AIR HANDLING UNG (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCn
PAID
Data Receipt#
HEATING UNIT (TO 100,110(1 BTU)
HEATING UNIT 100,000 BTU)
L
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
I$$LANCE DATE
�I
JUN .,9
C�� j+ 1994
L/
L�IY
Ch///P`
ISSUED BY:
BOILER - COMP (OVER 100,000 PTU)
NEW RESIDENTIAL MECH.-SQ. FT.
Owner or euthmiud a gent Date
OFFICE