24861 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO N ILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT
PLUM mOJ CT UJINI NG-MECHANICAL 24861
BUILDING DIVISION ewl.lnar:PROJECT Ines'nE1CATTON
BUILDING ADDRESS: ''!! /I SANITARY NO, APPIJCAI]ON SSUBMITTAL DATE
9117 PER Vl" UNIT# LOTH 3 111— 93
OWNERS NAME: _ (' PHONE-'.: CONTRACIOR'S NAME: LIC NO:
L t 1J L Kss.�3 yz NC CONIROLN
ARCHIIECDLNGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QPY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
SAMUES F. :ISAAC C, -r_A3i
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El E] Id' El
LICENSED CON'TRACTOR'S DF,CLARAT'ION APPLIANCES-RESIDENTIAL
pCZ Ihereby affirm that l®n licensed under provisions ofChepler 9(commencing with JOB DESCRIPTION
00 000
Section] )nf DivivinnJnf the Business and Professions Code,and my borrow is in PANELS
WErc
/ I q r
WE foe Intl_fifes. `/ I✓l 1/Q}_j .-1
FZm
License Class 1.10.k Oil 10 AMPS
N=y Date Commcmr 201-1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
FyZ� ARCI IEC'S DECLARATION OVER IIXIO AMPS
c z ti p I understand my plans shall be used as public records.
P E-t FEW SIGNS ELECTRICAL
�� Liecnned Pmfcesional
W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
,5 or I hereby affirm that 1 am exempt from the Contractor's License law for the
u134sFjr following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.MF.'Ri 1 I T.
C ° which requires a Permit In construct.shot,improve,demolish,or repair any structure L'0
to its ismarse,ako Ibex licam forsuch tmfileaxi eJstalement POWIiR DEVI < -
prior requires pp ,crani gn
WK<p0 that he is licensed pursuant the provisions of the Contractor's Licome Law(Chapter SWIMMING I E I3CTR1 i1 V sit u
D•X.rrL 9(commenang with Sectio.700 of Division 3.flhe Business and Praesxi.ns Code) 4 -� VALUATION
W:2, or that he is exempt therefrom and the Buis for the alleged exemption.Any violation.( OIITLEfS-SWITCH F_S-FIXTURES 3nar
Z G Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
t more than five hundred dollars(SNXR.
2p NIiWRE51DIiN-FI . Itt STORIES TYPE CONS'I'RUCHON
W~m I.os.wnerof Nepmpcny,ormyemployeeswithwagesauheirsolecompemation.
e3— 1 do the work,and the suYcl.re is not intendeduroffered basalt,(Sec.7W.Business
and Professions Calc:The Contractor's License Law does not apply In an owner of
progeny whobuildsorimproves theleon.and whodo essuchwmk himsclforthr.ugh his
emPloyees,pmvided,hmsuch improvementsa«non imcndMor.ffertdformle.IL OCC,GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did no,build m improve ton pmpse of
`ale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ [,;is owner ofthe property,anmxclusively contracting with licemedecammumrs to
construct the project(Sec.9044,Business and Prnfessiom Code.)The Contractors
Livers.Law dresnot apply,.an ownerofpropeny who builds orimpo,.thercon,ond / PERMIT ISSUANCE -DO
who contracts forsuch projects with o convacmKg)licensed pursuant to the ConVacmrs
License Low. ALTER-DRAIN&VENT-WATER(G) FEE SUMMARY
❑ 1 von exam,,under Sec. B&P C for this«amt BACK FLOW PROTECT.DEVICEOUTSIDE FF,PROTECT.
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,n REA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ lbereby affirm that l have a eenificaoe ofoomen„o self-imam.or a cerlificene of lr! T RES-PER TRAP RECEIPI'a
Worken'C.mpmsmion lnsuran<unacenificA copy thereof(Sea 38W,f.ab CJ which PARK FEE Y N
coven all employees under thispermit. GAS-FA.SYSTEM.)INC.4 OUTLET'S BUILDING DIVISION ItiFS
3v�o R13C
Policy N SION
Company GAS-EA.SYSTEM OVER 4 EA) PLANCHECK FEE
❑ Cathed copy is hereby furnished.
❑ CenifieJ Dopy is filW wiN the city inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADING 193E
CIETIPICATE 01;EXEMPTION MOM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Thismction reaction becompleseliffle permitis foronehundmJdollars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY EEE
or loss.)
I certify that in the Performance of the work for which this permit is issued,)shall WATER IIIA'TER W/V FINE[ELECTS
not employ tiny person in any rammer so as m become subject in the Workers' PAID
Compcn.vminnlaws.f Califorma. Date WATER SYSTEM/BEATING Date Rol N
0 z Applicant
z 0 NOTICE.TO APPLICAN-LlCriRcr making this Cenifica¢.f Elvern inn you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
F-' DObecome subject to the Worker's Compensation provisions ofthe Labor Code,you most
BUILDING FEF.
� > forhwith comply with a el provisions onbis porne,hall be deemed revoked.
W Q CONSTRUCTION LENDING AGENCY SEISMIC ITS
z I herebyaflirmthm lhemn.construction Iordingagency hathePMnrouneeof T HAL: -Q' ELECTRIC 193E
U O the work for which this Pont is limed(Sec.300.Civ.C.)
Lender's Name PLUMBING FRE
D" F Leader's Address QTY. MECHANICALPERMIT FEE -O�
U I certify but I have mad this ap,licmion and stain the,the above infmmelbn is MECHANICAL Flili
correct.l agree In comply with all city and county ominances and some laws rda,ing to PERMIT ISSUANCE:
builJingconatruction.:mdhcrcby authorize representatives ofthiscim to enter upon the CONSTRUCTION TAX
(� Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree m save,indemnify and keep harmless tl«City of Cuperlino against
liabilities,judgments,costs and expenses which may in any way twelve against said City AIR HANDLING UNIT(TO 10.0010 CFM)
yuence of the gra: .I this tl.
in s I in " � 3/I��93 A HAUST OO ON]'I`QOVTMUCT) IO,gXI CFM)
rc (ApPLcunUCommmor, D.d! EXHAUST HOOD(WIDUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Rei N
Will the applicant or furore building occupant store or handle humrd.us material TOTAL: ^�
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Beallh and Safety I IEAI'ING UNIT(OVER 100, 00 BT'U)
Code,Scuion 25532(a)' VIII4'fILATION FAN(SINGLE RESIDE
❑Yes ❑No
Will Ne applicanmrfmum building oceupanluse equipmen,ordevinaw whichemin BOILER-COMPOHPOR IW.0009TU) f1155UANfiI'.DATE
hazmdous air contaminants us I,Fned by the Bay Area Air Quality Management BOILER:COMP(OVER 100,000 BTU) P AMU
TF1 1 'Il(QJ'�(Q�
Pimm ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. MAR L MU
have lead the hvordou materials requiremcme under Chapter 6.95 til the
California Health&Safety Code.Sections 25505,25533 and 25534. I understand than CI I Y Ur V Ur Gn I IINU
Hint building does not currently have atonal,that it is my msponsibility to notify otic
meuponl of the reyuimmmns which must he mcl,aar t.issuance"I.Cenifvote of
Ocwnpney. cI `ff
Owner or autlorieN agent Dam TOTAL: ISSUED BY: �N ��
OFFICE