24682Y
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO. 24682
/N n QLI6 H Z
BUILDING ADDRESS: L /
ai4so CO/IAItAUAS In¢ wo CA 4s'0 �}
IT # OT p
SANITARY NO.
APF-ic7RONSUBMH7ALDATE-
1
OWNERS NAME: N PHON .: 2$l qbp
A"kE R.NATA1Qk5AJ
CONTRACT'OR'S AME LIC NO:
SON
N/C
❑
CONTROLp
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ITmoi
RCIIITECT/ENWgR'ti FR: �s ,SSA(- LIC NO:
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DAIS I ��. ^ C
4 IT CA
CONTACT: PHONE:
(LIDS) Z z, � � � U �
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I PERMIT ISSUANCE
/
LICENSGDCONdunderOR'SDECLARATION
I herehyafi III onSE liCONTRACTOR'SD DECLARATION
(commencing with
Quaision
APPLIANCES -RESIDENTIAL
Ino E IP�LON
Section Rl00)of DivSof Ne Business and Professions Code, and my license is in
PANELS
{/-y/�/�py�l `Qi
fill force and effect,
License ClassLic.M
UP T0200 AMPS
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records.
201 - 1000 AMPS
SQ. Ff. FLOOR AREA VSQ. IT.
*24
OVER IOW AMPS
SIGNS ELECTRICAL
g—i{r
Licrnaed Professional
OWNER -BUILDER
SPECIAL CIRCUIT/MISC.
m the CoATION
from
1 hereby affirm Nm 1 am exempt Rom the Convertors License Law for the
TEMP. METER OR PoLE INST.
following mason. (.it to 1031.5, and Professions Code: Any city or county
which 1. tills, i
permit re coaatmct, alar, improve, demolish, repair tiny swnere
its is n
pdanoltsicensed alsorequitest file.ei
fi
forsirchCo
POWER DEVICES
moisiin, mnces Lov(Cmmem
n 3 of Contractors License Luw (Chapter
that he is licensed pursumun the pmvisi Division
9(commrncing with Section 7000) or Division3ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
mind he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjects the applicanno a civil penahy of
1
L � w
OVIlETS-SWITCHES RXTVRES
L'
not more than five hundred dollars ($500).
❑ I,mowmrofthepropeny,ormyemployeeswithwugesastheirsolecomNnsation,
will do the work,and the structure it not imeadedoroffered forsale(Sec. 1044. Business
and Professions Code: The Commences License Low don not apply to an owner of
NEW RESIDENTIAL $Q. PP. A r
_ STORIF,S
�p\YRS
'TYPE CONSTRUCf10N
- t_,
properywhn mildsmimprovesthereoo, unit whodoes such work hireself.,though his
employees, provided that ruclt improvements are nm intended m oRerd for sale. If.
TER
.GROUP
RES. UNITS
T'OTA ,
however, the building of impmvemem is sold within one yearn(completion, the owner-
builder will have the burden of proving fast he did not build or improve for purpose of
Q'fY. PLUMB 'PERMIT
asks.).!VU
❑ 1. "owner oftbe property,umexclusively contracting with licensed conwctorsto
NE
APN
construct the project (Sec. 1044, Business and Professions Cale:) The Contractor's
License Law doernot apply to an ownerof,imperty who builds in improves thereon,and
-T
PIMMITISSUANCE
whocont=mforsuchpmjectswithacontmctor(s)licensMpumuanitolhe Cmmcioes
License, Law.
ALTER - DRAIN&VENT - WATER (rip)
FEE SUMMARY
❑ I am exempt under Ser. B & P C far this reason
BACK FLAW PROTECT. DEVICE
GuTSID EF
SANITARY YN
RECEIPT
Owner Dote
WORKMAN COMPENSATION DECLARATION
DItA1N5-BOOR, ROOF, GOND.
,,
SCHOOLTAX YN
❑ l hereby affirm that l have a certificate nrcomern to self -insure, me certificate of
Worktte Cmnpensation Insurance or ucertified copy thertof(SecJSW,IahCJ which
RECE1Pf#
FIXTURES - PER TRAP
PARK FEE Y N
coven all employee's ander this'.4.
Policy#
RECEIPT p
GAS - EA. SYSTEM -1 INC.4 OUTLETS
BUILDING DIV ION FEES
Company
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK IEE
d
❑ Certifiedcopyisherebyfumished.
GREASRANDUSTRL WASTE. INTERCEPTOR
GRADING FEE
❑ Cenified copy is riled with the city inspection division.
CERTIFICATE OF EXEMPHON FROM WORKERS'
GREASETRAP
SOILS FT:
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2000.
ENERGY FEE
(lhissection retail not ne completed ifthe permit it reform hundred dollars(SIW)
or less.)
WATER HEATER WNENT/ELECTR
(certify tot in the perforrnance of the work for which N. incrou is issued, l shall
not employ any Person in any mmuter so as to become subject to the Workers'
PAID
WATER SYSIEM/rREATTNG
Crmpensutioul.awsofcalifomia. Date
Dam Receiptp
Applicant
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. Ff.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you muss
comply with such provisions or this Permit shall be deemed resulted.
BUILDING FEE
I
SEISMIC FEE
DO
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then is a construction lending agency for the performance of
the walk (a, which this permit is issued (Ser. 3091, Civ. C.)
TOTAL:
ELECTRIC PEE
Lender's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender's Addrev
1 certify that I have read this application and state that the above information is
acct. l agree to comply with all city and county Ordinances and state laws odatingm
PERMIT ISSUANCE
MECHANICAL FEE
buildingeonstriction, and hereby authorize representatives ofmis city homier upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep hamleas the City of Cupertino against
littlothiex,judgments.eoetand expeaseswhh,h may in any wayaccrusm,ma said City
AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of theung of nlaispenot.
n a - 2.1110
AIR HANDLING UNIT (OVER 10," CFM)
Sisnuturc or PlicanVComracmr� Dam
EXHAUST HOOD
�1
PAID
HEATING UNIT CFO 100,01(10 BTU)
HAZARDOUS MATERIALS DISCLOSURE
one Receiptp
Will the applicant or future building moupant share or handle hazardom material
as defined by the Cupertino Municipal Cod, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,01VRTU)
TOTAL: - Q
VENTILATION PAN (SINGLE RESID)
e71
Cooke, $Kll Yea, ❑ No
El
❑ Yes
BOILER - COMP (3HP OR I W,OW BTU)
P ISSN A�CF�DAUITE
Will theapPlicantnrfuwm buildingoccupantuucgoipmem ordeviceswhichemit
BOILER -COMP (OVER 100,0011 BTU)
hrmalour air conraminanla as defined by the Bay A. Ab Quality Managemem
DNM,17
❑Yes C3 No
FEB 41993
NF.WRESIDENTIALMECH. SQ.Fr.
I have read the hazardous materials m,mmusents under Chapter 6.95 of the
California Health &Safety Code. Sections 25505, 25533 and 25534. 1 undcrstaad that
11140
if the building does not currently have a mason, that it is my responsibility to notify the
CITY U1- UU"CTI
a:cupanh of the Iequimmems which must be met prior to issuance of a CeAficase of
Occupancy.
1 I
ISSUED BY: V ��+
Owner or authorized agent Date
TOTAL:
OFFICE