25059{;}APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINOPERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUM nING-MECHANICAL
IIUILDINGPROJELTIDENTIkICAI'ION
NO. O (�
`7
BUILDING ADDRESS. -
c?o,2 30 SrEy6N.5 ' �2� 19/0"tUNIT0 LOT.
- 11111111 11,
APPLICATION SUBMITTAL DATE
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rONTACT:[ �/ ,R46A44. PHONE:
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28 W C,7YCclvsr 5-9-SSo7
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DC ELECT PLU N M :CH
PERMIT ISSUANCE
LICENSER CONGRACfOR'S DECLARATION
I herchyaffirm that l am licensed underprovisionsofChapter9(commencing with
Section 70001 of Do isio Sof the Business and Pmfessiom Code, and my license, is in
full fore and effect. M
U.Cloo S -I Lit.X �OSa//Z
APPLIANCES - RESIDENTIAL
PANELS
UP T02fp PS
JOB DESCRIPTION
�A
D. Contirmou
ARCHITECTS DECLARATION
I understand my plans shall be used ss public records. �'-
201 - 1(100
S
SQ. IT, FLOOR AREA
C, e �J -
S/SQ. FT.
a, r
O - 1 %
ELF
/,
/
Limmecl ProfessorialLTRICAL
OWNER -BUILDER DECLARATIONL'�AL
CIRCUTf/NRS .
I botchy, suffixed Nam at 1 axemJe from the Convectors License Law for a
following reason. (Salon 7031.5, Business and Professions Code: My city or cow
TEMP. INST.
winch requires a porrom to consuum ober, improve, demolish, or repair any structure
pian m it, issuance. alto becomes; theeppliciot farsuch permiuo fileaaigned statement
D V
that he is liccnsd puesuant to the provisions, of the Cmueanrs License law (Chapter
9 lmmmencing with Semim 7")of Division 3 of me Bmiruu end Professions Code)
mthat he isn<mp Nuefrom and me bssis fonhedlegdcxemption. Myviolatiou of
Section 7031.5 by y epplicast for a permit subject,the applicant to a civil perulty of
Secan
SWI GPOOL ELE IC
VALUATION q
D. l v L/�/
S - SWITCHES- FIXTURES
not mom Jun five hundred dollars(S500).
C] I,uownerofNc Mro ry,mmyemployecswimwgmwss irwlecampcaseuon,
NEW RESIDEN'17AL ELELTR _SQ. FT.
STORIES
TYPE CONSTRUCTION
willdo the wark.and thenwcture is not intended] oroffered forsale(Sm.'7W, Business
ad professions Cade: The Contractors License Law does net apply to an owner of
imoves thcuan, and who does such work hi msclf err through his
pzapery w bo builds mp
_ cmployeca.pnvidedmmwch imt inunddmof(eudforonr.
OCC. GROUP
FS
R. UNITS
within
is mid min oneyear ofimprovfion,meowner
buil ding ordson
butlhorser iH fpmvinistolde
builds will have Je burden of pwvine Jw he did rot build m improve for purpose of
We)
❑ Las ownaofthe property, wnexclusivel mmuctin ith licensed conueaaesto
Y Hw
FLOODZONE
APN
('OFF: V :t,iQil,2:atrR'�^'aa.clw. A
6�2y,, PI:UMBING PERMIT "�' .FEC^`--
r:vs _, 4dFNNahn99exs'Aa.e um tUt l .. sustu[`dtrt4
ULE the oesace (Sa. 7t%4, neirif,r are, w1h.limu Code:) The Canuwrord
U. Isw does not appl y .. owner of pmperry who builds or improves meum, and
ppRg(pp ISSUANCE
IT
whomnuwu for each Prajecuwithamntmctud.) licensed porsuantm Ne Convwm'a
U. Lew.
-AT-WATER LA
ALTER DRIN&VEN HEA;PEE
G° a!•": crym"'r'
SUMMARY,1a,,
❑ 1 am cxanp tarda Sa. . B & P C for mis reason
BACK FLOW PROTECT. DEVICE
bIllp, VLES
SANRARY Y N
R 10EIPT p
Owed Date
WORKMAN COMPENSATION DECLARATION
❑ Ihanbyeffvmtlmlhaveaceniri u ofco ttowlf.insum,oraanificweof
Winds., Compn,wim Insurance or a certJid copy thereof(Sm. 3800, Lab C.)which
covers allemploya's rode, this permit.
pdh. g
DRAINS-FL130R. ROOF, AREA. COND.
SCHOOL TAX Y N
RECEIPT #
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPI'X
GAS - EA. SYSTEM -I WC.4 OUTLETS
BUILDING DIVISION I=
C�panY
GAS - EA. SYSTRM-0, �
7 1
P HECK 26 2�_aEV
❑ Cenifid cap, u hcmby fumishd.
GREASFANDUSTRL 57L'INTiR ]3
R
G ING FEE
❑ CmiEd copy is fill with the city inspeeOmdivision.
CT41TB9CATL•OF EXEMPTION FROM WORKERS'
GREASE TRAP 1 V
SFIJ FEE
COMPENSATION INSURANCE
(This... mednot be completedHNe permit is forme hundred dollars(S100)
SEWER-SANITARY-SlDATE200 ��
ENERGY FEE ZI LI
or]..)
WATER HEATER W/VENT/ELECTIt
737�s
I certify met in me' Kin ce.fthe.,itfor which this permit is issued,Isbell
trot employ toy person in toy mama w ss to become wbject In the Works%
_
PAID
WATER SYSTEM/IREATING
Compenwtiomiswsof Celifomis. Dna
Dau ReceiptN
APplinnt
NOTICE TO APPLICANT: If. after making this Certificate, of Exemption, you should
NEW RESIDENTIAL, PLMB. SQ. FT.
TOTAL C7 0,3,0
becmne subject to the Worker's Compensation Provisions tithe Labor Code, you most
forthwith comply with such provisions err this permit shall be, domed revoked.
BUILDING FEE 1-a
SEISMICFEE 3
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction Imding agency for the performance ofELECTRIC
the wok for which this permit is issued (Ser. 3097, Civ. CJ
IEEE
- -y r. s 4.*.+- - V m moi-
`A � L
QTY `f�t«``q�1� MECHANICAL PERMIT L rd .FEE
�... ,.�{ t n. .,„-
1T' .x�-
PLUMBING FEE /—
Lenders Name
Lenders Address
1 certify that 1 have sad raiz application arta sura than the above information is
correct.
cortat. lags to comply with allcity and count) ordinances and state laws relating to
�"u' `PERM
�SSUAa.t'....
PFRAfR ISSUANCE r
MECHANICAL PEE O fR
building construction, and hereby authorize mMesentatives of this city toenur upon Che
al,o,emcnti,i propcny for IospeNon p ,oses.
ALTER OR ADD TO MECI I.
CONSTRUCTION TAS
AIR HANDLING UNIT (TO IBM CFM)
(Wp agree Co save, indemnify and kap hermits, the Cd, of Cupnim against
habilities,judgmrnu.msts and expenses which may in any way accrue against said City
AIR HANDLING UNIT (OVER10.0I0 CFM)
PAIDarc
o�� ming of this Prmt.
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simn/
r
�phcamlcantmmorDu
UCTI
EXHAUST HOOD
HEATING UNIT (TO 100.000 BTU)
HniARDOUSildAg DISCLOSURE
1 Rccnpt a
HEATING UNIT OVER 100,0(0 BTU)
T
al
N'illthe 'heC.applicant m, future Moriilldimg occupant, Chapter
ardmis bband Safety
or handle I Rabb
ss def red by the Cupertino Mwicipnl Cade, Chapur 9.12, and the I Ieahh and Safety,
Cade, Salim 25532(ldr
❑ Ya AN. .
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will me appliovmrfummbuildingoccupwtuu equipment ordevices which tout
havrdous air cometedivunu u defined by the Bey Area Air Quality, Management
DimictT
BOILER - COMP (3HP OR Io0'” OTU) '
/k
P A I,
BOILER: COMP (OVER 100,0(10 BTU)
a�
11 Yes JQ No
I have read the hersNous mnerod, a tturem nu ooda Chapter 6.95 of the
NEW RESIDENTIAL MECH. SQ. FT.
t1�I 13 1993 - -.
JUL
California HeaA S
th afety Code; Satimu 25305, 25537 and 25534. L under and that
`
if me building dm not currently haven berunt, than it is my responi ibility le medfy the
oavjwd of the, ro uimmam which mean the man prior to ianunce of a Cenifiwu of
C� Y VI- V UFCD I Ili V
ISSUED BY: v -
Owmrmaumorird agem. Data
A