24659:Yz
00
'zi
Vf
.! Z
r?
�J
<J
:z¢
:-U
-F
JQ
tnJ
'?uca.
rn
:za•
:.o
L
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING- . ECIR AL
BUILDING OFUIVTSION APPLICATION/PERMIT. PLUMBING• MECHANICAL
",%2&''.(V,4AiBUILDINGPROJF.CTIDENTIRCATION+7'°P,:dS,)&4 I
PEBMH'NO,
a� � ^ 5 N9 r /N
L Yl•
BUILDING ADDRESS:
SANITARY NO,
APPLICAUON SUHMOTAL DATI.
14 2 pV7 ClLft7K'-%PIVD US � � LOT.
—6�2
ON NERS NAME: g 1'IIDNE:
F {JO
ICHIIECT/ENGI NEER: LIC NO:
w �
C TRACTOR'S NAME: �y LIC NO:
�./jprgaa•.,'
ADDRESS: ���(J
a- s .Ira
NIC
F
CONTROLp
1 l 2
CONTACT: PHONE!
/�.N� 77
e`
ELECTRIC PERMIT 4z -.
'S'^•t'-,;r_`"-
BUILDING PERMIT INFO
B- LGG SLE PLUh1B SECT
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Iha I am licensed under provisionsof a,1119 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section 7006) of Division 3 ofthe Business and Professions Code, and my license is in
full force and effect.
PANELS
y
T
net Clazs LI[.N
UPTO 200 AMPS
Dme Comranar
201 - 1000 AMT'S
ARCHITECTS DECLARATION
1 underswusednd my plans shell be used as public rceonls.
OVER 1000 AMPS
111. FT FLUOR AREA
` >a
`GJIJr
S/SQ. FT.
SIGNS ELECTRICAL
�lV
�+
Licensed Prefcssional
OWNER BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt (rain the Contractors law for the
TEMP'. METER OR POLE (NST.
following won. (Section e: Any
Code: Any city or county
which construct, ether, improve, demolish, or repair any sou
t, Sher. land ve, demolish,
o permit in comes
its i'
i¢censed.elsolequims Neapplicamfar
th. cam
POWER DEVICES
did he theSuch Caupcmtitm Licasigncd(Chapter
that rt islicensedpursuantmtheprovisionsat theethe uanors and Pro law(Chapter
9 (commrncing with Section T000)of0ivision3of Ne Business and Prmfeuimru Cade)
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicannoa civil penalty of
SWIMMING POOL ELECTRIC
^ . ' VALUATION
/ CJ� ^ �N
" v
UTLEJS-SWITCHES-FIXTURES
not mom Nan five hundred doll. ($500).
❑ 1. azowner ofthe properly,urmycmployess with wages ax their sole compersudon,
STORIES X TYPECONSTRUCDON
NEWRESIDENTIALELECTR _SQ.FT.
will dothe oek.and the stmcutmis notimcmded scattered forsale(Sec. T(kW. Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Insularly wh mildarrimprovastheeeomand whodoes such work hireSelforthroughhia
ownernpioym.pmvided ntsuchimpmvemennu notinwnde moffe fesde. If.
Ik
OCC. GROUP ItL•S.UNITS
/' A
I
theowntt-
boweer will have
impmvementi that he
inot build improve
burden
builder will have the burden of proving that he did not build m improve for purpose of
Saba.).
❑ I.azownerof theprepcnY•em exclusively contracting with licensed convacmnto
—caQ'Y,'. iYs•a MB
FLOOU 205E
APN
comfort Ne prejal (Sec. 1004, Business and Professions Code:) The Contractor's
LicenseLawdoem
anot apply anownerofprapery who builds a improves thereon,end
PERMIT (SSU CF " t �V
whosommuctsforsuch projectswthaconttacams) licensed punuanl to the Contractor's
License law.
ALTER- RAIN&VGNT-WATER (EA)
�' 9 '4
;}""y-s�FEE_SUM_MARY��uay"'.ix'r�„s
❑ 1 em cxonpt undo Sec. B & P C for this ..a
BACK W PRO
OUTSIDE
SAN ARY Y N_
RECEIPTN
Owner Date
WORKMAN COMPENSATION DECLARATION
DRAINS -FLOOR, ROOF, AREA. COND.
SCHOOLTAX YN_
a3 Ihertby effimt Nvlhevc acertificate of cmnunt la adf-insum,on artifica¢of
Warkars Compensation lcel ropy surnmerm. cel thercotl5ec. 3800 lab C.) which
RECEIPTa
FIJ(TIIRFS"PER TRAP
PARK FEE Y N
GAS - EA. SYSTEM. INC. 4 OUTLETS
cosers dl cram de under this petmin,
Policy N
RECEIPT N
DING DIVISION FEES
FEE
isc-glilary___GAS
- EA. SYSTEM -OVER 4(EA)
thed copy is hereby famished.
ORL- SFIINDUSTRL WASTE INTERCEPTOR
erdfed copy is filed with the city inspection division.
GPAD11 IWIl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
GREASE TRAP
SOILS
SEWER - SANITARY - STORM EA. 200FT.
ENERGY
This section need not be completed ifthe permit is forone hundred dollars (SIM)
or less.)
WATER HEATER W/VENT/ELECTR
I cerifytha in the perfarmanceofthe work for which this permit is issued, l shall
nmI employ any person in any manner so ss m berome subject or the Workers
PAIQ
WATER SYSTEM/TREATING
Compmuad mi Llwsof Calimmia. Dam
Date t
Applicant
NOTICE TO APPLICANT: If, after making this Certificam of Exemption. you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject to the Workers Compensation previsions of the labor Code, you must
forthwith Comply with such provisions on, this permit shall be deemed revoked.
BUILDING FEF.
i
SEISMIC FEE Q
CONSTRUCTION LENDING AGENCY
I hereby affirm Bud there is a construction lending agency far the petfitura tt of
the work far which this peir lis issued( Sec. 3097, Civ. C.)
Lenders
TOTAL:
ELECTRIC FEE
4
Name
tenders Adjuncts
•. ..• -_... h .._,
QTY. I', _, `0 --MECHANICAL PERMIT .,`FEE
s" r
PLUMBING FEE
I ecnify that 1 have mad This andicdurn and Smitthat the above informtioa is
rtith
correct. I agree to comply wall city and county ordinances and slate laws relating m
-
PERMIT ISSUANCE
MECHANICAL FEE
buildingemi.... iso. and hcrchy authorize mpreaenmtivn of Nis citymemer upon the
above .mentiored property for inspection purpaus.
ALTER OR ADD TO MSCI 1.
CONSTRUCTJONTAX
(We) agree m save, indemnify and keep harmless the City of Cupenum against
liahilaies.judgmcn¢. crisis and expenses which may. any wsyaccrueagainsl said City
AIR HANDLING UNIT G 0 I OJIW CFM))
innmsryuencc of lit ung This perm%
AIR HANDLING UNIT (OV f:R 10000 CFM(
S. n fAppl icon/Comracmr Dae
w
EXH AUST HOOD
F:\IU
((EATING LfN'IT(TG I(ams'(111,101
IIAZ:Vi000SNATI-RIALSDISCI,OSUItE
ILuc Itsv'vP;
Will the applicam or future building occupant store or handle hmardous material
as defined by the Cupertino Munidgid Code, Chapter 9,12, and the Health and Safety
HEATING UNIT (OVER 103,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
CodeSaint..25532(.y?
x)?
11 11 No
❑ Yea
ISSUANCE DATE. '
Will NeepplicamorBnurehuildingwcupant use equiptnemmdevitxs wlJchemil
is ei,^amamirtanta as defined by the Bay Area AG Qaality Mnug—t
BOILER- COWL RIP OR 100,0011 BTU)
S� p
P A I D
BOILER- COMP (OVER 100,030 BTU)
❑ Yes ❑ No
NEW RESIDENTLAL MECIL SQ' FT'
1 have read the ndadours materiels socramonal under Chapter 6.95 of the
MAR O
1993
Califomia Health & Safety Code, Sections 25515, 25533 and 25534. 1 und.und thaI
a%J
if the building does not currently have a column, Sher it is my responsibility m notify Site
CITY
occupant of Ne rey.mchis nu which most be met prior m issuance of s Certificate of
Uf V 7 '
Occupani
ISSUED BY:
r Owner s i uNorired agent Data
OFFICE