24690APPLICANT TO FILL IN INFORMATION. WITHIN RED LINES — USE BALL POINT PEN ONLY
CITY OF UUPER'i INO
INILDTNG DIVISION APPLICATION/PERMIT
BUILDING. -ELECTRICAL
PLUMBING -MECHANICAL
BUILPROJECT IDENTIFICATION
.a � w � O
PERMIT NO. 24690
L fl•�l
BUILDING ADDRESS:
SANITARY NO. -
APPLICATION SUBMITTAL DATE
2oc,220-DI� IGU6,5
UNIT#
1.01a
I-' �V
OWNERS NAME: - 1I11,5 y� PUONI?:
�• o N N j . S 1-1 A Qq N IC-DEL.M A�
,"V
CON'I'RACI'OR'S
NAME: LIC
NO:
N/C
❑
CONTROL p
.RCIIIIECT/ENGINHER: LIC NO:
ADDRESS:
CONTACT: - PHONE:
1/�/ G //')Q �]
I Jc22AI► ,`' �� — V% _2�o
Q'fY.
ELECFRIC PERMIT'
FEE
BUILDING PERMIT IN •O
@I. G [I LU
CCC
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Iherebya Division
l3.f,hnBu u.aid visionsof Ch Cole.adrayhocingwith
hatintenan0)of Division3rf tM1e Business and Professions Cale. and my license is in
Poll forceandeffem.
) Licensee Clercs Lica
APPLIANCES - RESIDENTIAL
PANELS
UP l'02(XIAMPS
IUB DESCftIPI'10
201 - 1000 AMPS
Dam Contractor
ARCHITECTS DECLARATIONOVER
I understand my plans shall be used as public records.
I(XX) AMPS
SIGNS
SQ. FT. FLOOR AREA
Sm. ET.
Licensed Profexsinnel
i
OWNER -BUILDER DIth[. CommiION
1 hereby afhem Ilmt 1 notER exempt from the C9mhaerra License Law for the
SPCCIAI C I, '.
P
i s/�a
o
following reason (Section 703 L5, Business and Professions Code: Any ciym<oumy
TFMP.M �R L' T.
9E
N
i which requires a Permit to construct. alter, improve, demolish, or repair any swnure
prior m its issuance, also requires the applicant for such permit to file a signedactemem
POWER DEV�E
that he is licensed pursuam to the provisions of the Comment . . Lleenx Law (Chap—
I 9(cmnmencing with Seador,700) of Division 3m the Businessand Professimns Code)
S TNG POOL I3LECfRIC
VA///L���UATION !1A
d thefor. hazisfrnhcalleged
or 7031.5 by s,liciexemption. Any violation of
• subjects the applicam toacivil penalty of
' !
{/� �1 C V�—✓
4
OUTLETS - SWITCHES- FIXTURES
oul morethan vmtyapplicantroe$permit
1 C1 marc than five hundred dollars ($500). -
htestructe,ortnyemtended withwagesasale(Sec. coogmnealinn,
❑ Lthe wok,
`V
NEW RESIDENTIAL ELECTR — SQ. FI'.
STORIES
'1'YPG CONS'T'RUCTION
an for a4,Business
will dahewons
and Professions Code: The Contactors License Lew does not apple loan owns of
Carli heCoeisoolis License do ot apply to
preJis
own enywyees, pdsor ed that sucthereon, improvndwho aressuch work himseeredfrrugh his
own employees, prov idea that such improvements are not intended of roared Bu sale. If,
OCC. GRO P
RES. UNITS
however,the orimprovementiesoldwithi noneyear of completion,theowner-
avet a
twill have the burden of proving Nm he did not build or improve for purpose of
QTY.
PLUMBING PERMIT
FEE
alt.).
ssh,.L
❑ I, ns nwnerofthe prrpcny,amudusivelycontrecangwilM1licensedconlmnors to
FLOOD ZONE
APN
omtrum the Project (See 0044. Business and Indications Crdc:) The Contractor's
License lawdoe.snot apply to an mwnernfpropeny who buildsor improves thereon, and
PERMIT' ISSUANCE
whocomacts for such projects with acrntravions) licensed pursuant to rhe Commenva's
Liven. Law.
ALTER (FA)
r
ITESUMMARY
❑ 1 um exempt under Sec. , B & P C for this reazon
BACK FLOW PROTECT. DEVICE
OUTSIDE EE
SANI'T'ARY YN
RECFIpf#
Owner Data
WORKMAN COMPENSATION DECLARATION
DRAINS-PLOOR,ROOFAREA,COND.
,
SCHOOLTAX YN
I hcrebyafftrm that l have u certificate ofconxnt to self. n"are cenificata of
orkers Compensation lnsumnce orecenified copy thereof (Sec. 3ilZ Lab CJsvhich
XTURES-PER TRAP
RECEIPT#
PARK PEE Y —N—
GAS - HA. SYSTEM -1 INC. 4 OUTLMS
��
is all employee's under this pemmit.
Poli .y p
RECEIPTp
BUILDING DIVISION FEES
Company
GAS - FA. SYSTEM OVER 4(EA)
PLANCHECK FEE
❑ Cerifted copy is hereby fomishal.
GREAS Fill NDUS'I BE WASTE INTERCEPTOR
GRADING FEF.
�T Ctnifted copy is filed with the city inspection division.
7`
CER '1'IPICATE OF EXEMPTION FROM WOR PERS
COMP17NSATION INSURANCE
GREASE TRAP
SOILS PEE O ��+
SEWER - SANITARY - STORM EA. 2001eI1
ENERGY FEF.
(This section rad not be completed ifthe permit is Intone hundred do11am($100)
or less.)
loarifylhut inlheperfommnctofthewmi, forwhichlhixpermitisiomind,[sha]1
WATER HEATER W/VI?NT/ELECTR:77
nm employ any person in any manner so as to become subject to the Workers
PAID
WATER SYSTF.MaREATING
Compensanionlawsof California. Data
Applicam
Data Receipt#
NOTICETO APPLICANT: IL after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
subject to the Workers Compensation pmisioms of the Li Code, you mussfonhwilli
croply with such provisions err this permit shell he deemed revoked.
BUILDING FEEas
SEISMICFEE1
CONSTRUCTION LENDING AGENCYxt,to
hereby affirm that there is a construction lending agency for the performance ofELECPRIC
work for which this permit is issued (Sce. 309], Civ. C.) IandcrsNameLanders
VTOTAL:become
FEGthe
Address
QTY.
MECHANICAL PERMIT
FEE
PLUMING FEE1
cenify that 1 have read this application and sum that the above information isMECIIANICALFEC
correct. l agree to comply with all city and county ordinances I dsure laws rclming to
PERMIT' ISSUANCE
building emnstrue0on, and M1erehy muNoriumpruwmtivu of Ibis city to cote upon ThoCONSTRUCTION
aMwemenlioned property for Inspection purposes.
ALTER OR ADD TO MSCI I.
TAX
(We) agree to save, indemnify and keep harmless the City of Copenino against
liabilines,judgments.mx¢and expemseswhich may in any wayacerueage ins, said City
AIR HANDLING UNIT (1010,000 CFM)
in cionce of the gaiting of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
amrerf Appii anJConmactor Date '
EXHAU$THOOD(W/DUC)
PAID
HEATING UNIT (TO 100,(100 BTU)
HAZARDOUS MATERIALS DISCLOSURE:
Data Receipt It
Will the appfeam or fctua h tilding weapons some or handle haznrdoua mamrlal
asdefined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER 100,0001IG)
Cak, Section 25532(u)?
EI Y. 0 N
$
VEMITLATION FAN (SINGLE RESID)
Will heaPPlicom orfuumbuildingoccupant use equipment mrdevices ouch emit
BOILER- COMP(3HP OR 0.(1,G)
ATE
UNfB&
BOILER -COMP (OVER 100,000 BTU)
.nrtlom air cman m cards as deduced by the Bay Arca Air Quality Management
4ritT:
❑Yes 0 N
MAR - 41993
NEW RESIDENTIAL MECH. SQ. PI'.
1 have read the hazardous materials requirements under Chapter 6.95 mf the
California [Icahn & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not currently have natura , that it is my responsibility to notify the
CI I r ur wren I D+u
cupid of the requirements which most bo ten prior to issuance ofa Certificate of
Occupancy.
ISSUEDBY:
Owneror nutborixed agent Data
f.
OFFICE