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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
—BUILDING - ELECTRICAL
PLUMBING -MECHANICAL
CITY OF CUPERTINO APPLICATION/PERMIT
.BUHIDING DIVISION BUILDING PROJECT IDP.NTIFlCATION -'�
P[.RMTf NO
25061
BUILDINGADDRGSS:
SANITARY NO.
APPLICATIONSOBMTlT AL DATE
S/-�"7..
2oZ3o C ✓Li i ^KVIC Uh'ITp OTa
1
OWNERSNASIE: PHONE:
CONI RAM OR'S NAVE; LIC NO:
NIC
CONTROL#
RC1 ECTTNGINLER: LIC NO;
ADD ESS:
CONTACT: PHONE:
-asiP, 1 I pyp,CpR1CPBRMI,�P� yW� . MRIt+,x ,: "'' i,PEBPI'+
93' i va.:'xn '-1' •:"'"°'sS""'^ may'=""
-
: iizr".',`'1'tS% BUILDING PERMIT INFO: "11
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
1:1 El 11
LICENSED CONTRACTOR'S DECLARATION
I hereaffirm that ro
M' am licensed under provisions of Chapter 9 (commencing with
APPLIANCES -RESIDENTIAL
IDH DESCRIIH'ION
PANELS
Section RgOt of Division Sof the Business and Profusions Code, and my license is in
fun mrte and effect.
Li.7S117 4 Lic.0 yl
UP TO 200 AMPS
eG
r
Date Contractor
ARCHITECTS DECLARATION
1 undersand my plans shall W used as public records.
201 - IOW AMPS
SQ. FT. FLOOR A SISQ. FT.
OVER 10D)AMPS /
SIGNS ELECTRICAL
Licensed professional
OWNER-BUILDERDEutARAT10N
1 hemby than I am emmpt from the ContranaR law for sh<
SPECIAL C[RCIRT/MISC. 1
following won. (Section 7031.5. Business and Professims Code: My ciry or roomy
n. (Se a: My
TEMP. METER OR POLE N'ST.
which requires a permit to construct, alter. Improve. demolish, or repair any strumae
priori, its issuance,also requvee theepplicat, forsuch normal to file. signed alsmman,
r•sL
POWER DEVICES
DATE
that he is licensed pursued to the provisions of the Contsactoi s Liecve Law (Chapter
9(commencing with Section 9000)of Divisioa 3 of Ne Business and Professions Cade)
_- ATION
SWIMMING POOL ELECTRIC
mitts, he iseaempt therefoor and the basis fm thealleged eaampton. My viobtionof
Section 70313 by any applicant for a permit subjects the epplicanno a civil porNty of
OUTLETS-SW17CF1FS -FIXTURES
'
am more than five hundred dollars($500).
❑ I.nownerofsheproperry.mmyemploy withwagesestheinolecompenndon,
NEWRESOENTIALELECfR_SQ.FT.
STORIES
TYPECONSTRUCIION
-
do shewmk. Cad the 7O 44.
he Contactors License Lawmaims
and Professions Code: The Contractors License law does not apply to an owner of
and apply
property who builds or improves tmreaa, end who dms such wo& hi msel f or through his
ownemploYeo,pmvidMmp mehi areno,imendedmpleemdforeels.If,
OCC. GROUP
RES. UNITS
TOTAL:
tiswlldwi
�wevWilder, she have theof pol that he didnone yam of completion, theownm-
Wilder will have Ne burden of proving that he did not build or improve for purpose of
all
❑ I.esownttafthepropeny,amexclus 1 cmvectin with licensed contractors to
ve Y 8
FLOODZONE
APN
'.. CFeL :+s INC.ruxas.::ufn xal.^ „nmlw4Lyypfi.
QTY: PLUMBING PERMIT��,+,w'3wPEE.7;•
:.,i•3 naawaxaaty+aw# w.aw.`a8
mNbYtl the p101al ($<L. 7B14. BLLM1lneba and PfOfeSslo119 Cad[:) TI,C f-'onnaClaf e
licrn¢Iawtloanot epplyaanowncrofpropeny whobuildsmimprovntherean, antl
PERMITISSUANCE
who emvam fm such projects wi th a rontnctor(a)1 icmxd punuan t m the Cmtrecmr s
U. Law.
ALTER - DRAIN & VENT - WATER (HA)WAR
FEE SUMhY,s
-- - -I - ---.
'.�;;tIR .. '1'>�4'ID
_. ,.
[31 am e.endr under Sec. , B & P C far This reason
BACK FLOW PROTECT. DEVICE
SANITARY YN
RECEIPT#
Owns; Dea
pRAINS- FLOORROOF.
, ..
WORKMAN COWENSATION DECLARATION
SCHOOLTAX Y N
❑ Ihacby off thulhaveaccrtifLetc of mnamlo xlf-insure, Oraartificare of
Wakm'Cpapmpensetion ldrasuyrtanaemaccr,ifed copy thereof(Sec.3gW.L.b CJwhich
Puliryxlf^'p� Dn/e lis/ Cis c G.
RECEIPT#
FIXTURES-PERTRAP
PARK FEE YN
RECEIPT Is —
GAS- EA. SYSTEM. I W'C.401RLETS �
BUILDING DIVISION FEES
CmnW^y
GAS - EA. SYSTEM-OVM 4 (EA)
PLANCHECK ME
❑ CenJd eopy is herebr f rmishN.
GREASFIINDUSTRL WASTE INTERCEPTOR
GRADING E
FE
x�'Cerifed copy is filed wish the city inspection division.
77'�
CERTIFICATE OFEMMIPTION FROM WORKER S'
GREASETKAP
SOTS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 2001T.
ENERGY FEE
(Thissectionnad nm W completed ifthe permit is for one hundred dollars P$100)
or lm.)
WATER HEATER W/VF.M'/ELECIR
. icenifyshatinshepedo moftheworkforwhichshispermitisismed,ishall
nm employ any penin in any mamrtr so as to become subject W the Wmke%
PAID
Cmnldn"ammlawsof Celifomil, Hate
WATER SYSfEMInUEATING
Date Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
Wwme subject to she Workds Camprnudon provisions of she Labor Code. you mus,
fmthwish comply with such Provisions Or this permit shall W deemed revoked.
I
BUILDING FEE
SEISMIC FEE
' CONSTRUCTION LENDING AGENCY
I hereby affml that them is a condensation lending agency for the performance of
the work for which this permit is issued (Sec. 3097, ❑v. C.)
TOTAL:
ELECTRIC FEE
Leader Name
Lenders Address
-and
^K- er+
QTY' S+'`�'irs,MECFIANICAI:PERMIT.7i(sv +D -s '''PEE
.yam T"' "'t' J C S?r. A"iii.+°
PLUMBING EtiE
I Certify that 1 have reed this application sane that Ne aWva mfohmeuo '
correct. l agree to comply with all city and county ordinal and state laws mlatng to
y1
PERMIT ISSUANCE o'o
MECHANICAL FEE U
building concoction, and hereby authorie, representatives ofthis city memerupon the
above-memimed property for inspection vmTlise,
ALTER OR ADD *10 MECIL. �. L t
CONS'IRUCTIOh'TAX
(We) agree to save, indemnify and kap hands, the City of Cupar rot against
and expenses which may in any way accrue again, said City
AIR HANDLING UNIT (TO 0."CFh11
in�liohilities,pligmen¢.cos¢
tie th /
nee of the grany'a�{hf shin permit.
AIR HANDLING UNIT (OVER IO.WO CFM,
EXHAUST HOOD WOU(CT)
PAID
,nature of Applicant/Camra..... Dale
HEATING. UNIT (TO IW (xIt BTDh
HAZARDOUS MATERIALS DISCLOSURE
Dam kvccipla
HEATING UNIT (OVER 100,000 BTU)
1
'TO] 'AI.\\:ea -L1 )
Will the applicant or future building occupum,are or handle butrandaus imi,c, I
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
VENTILATION FAN (SINGLE MID)
Code, Section 25532(.)7
❑ Yes ❑ No
'
ISSUANCE DATE
Will theappliranmfuambuildingmcupaT=Nuipmentordeviceswhichemit
BOILER- COMP DHP OR IW.D(0 BTU)
/' p R D
8-
BOIL.ER-COMP(OVER 100,000 BTU)
haaardau air mnamineats as defined by Nes Bey Ara Mr Quality Management
DuvidT
.
NEW RESIDENTIAL MECIL SQ. FT.
❑ Yee . 0 No
MAY 11-1993
I hive read the haaardous materials ralmoura nu under -Chapter 6.95 of the
Califorsta Health&Safety Cade. Sections 25505,25533 and 25534. 1 understand that
If the building does ml cum... tenan4 the, it is my mrpaudibility to natfy the
CIII Vf VUr- nEII4V
-
occupant of the meriveral which must he ma prim a issuance of a Cmifiote of
-
Occupancy.
cI
ISSUED BY: a l
.Owncrmaushma
ixcd gmt Dial, „
I TOTAL: .O
UrhlUt