24723 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELE RICA[ PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL /1 /I �/� 1�
BUILDING DIVISION BUILDING PR(IJEC'TIDENTLIFICATION 4 2 3
BUILDING ADDDRRH : a SANITARY NO, APPLICATION SUBMI'I'1'AL DATE
.2;ZJ 43 �� O�� �DNIT4 LOTH •'• — V�.-i
f'.gm O ERS AME: r/ 1� Pt ION 3� ONTRACrOR'S NAME: LIC NO:
�_VV
shC CONTROL
I
P
IDS /Id1CINEER- I I.IC NO: ADDRESS: ❑ ZZ 081
CONTACT: - sof PHONL:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLD ELECT PLUMB MT:CII
PERMIT ISSUANCE El 11 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RES ILNTIAL IDB DF.SCNII710N
pfyz Ihereby 7030)0Divisen in amBmin,i,mal Prumsic,,Cade commencing with
yF100 Section 9WlyafDivisit Implicensed Husinessand ProfesorCQNe,arc mmencise with PANIi '
5Rl full force and effect.
QG License Claws Lic.4 UI'T
y<y Date Contractor
Z O'ztZ— ARCHITECTS DECLARATION iR I000 AMPS SQ.17.FLOOR AREA $/SQ.FT.
OZ-0
I understand my plans shall he used as public records.
r^J; SGNS ELL 1 AL ..
Licensed Poresamnal
OWNFB.BUILDER DECLARATION IC#1 rDMISC.'
yp(OaU I hereby if,.that I am sumer from the Grammarian,License Law far the yf —
W 3 LL y following reason(Section 7031:5,Business and Profusions Code:Any city ser county i'.METER OR p v NST.
V.O¢ which requires a permit to conswn,alter,improve,demolish.or repair any structum
�tra�T� prior roe its issuunce,vlm reyuitesthe applicant for such permiun file aligned eta¢mem POWER DF l_
c <0 that he is licensed protect to the provisions of the Contractor's License Lew(Chapter
a%op' 9mimmccengwith Secti.701101of Division3ofthe Businessland Professions Cnde) MING POOL ELECTRIC VALUA'I'IOFJ,aia
,_,y orthutheisnentpuherefrom trod the bulls for thoull,,descmptlon.Any vinlalnn of
F G
Section]031.5 by arty applicam for a pramansubjects lheupphearnt ma civil pcmJly OUTLETS-SWITCHISS-FL%TURES rr��
nreA
t mare than Five Imaddollars($500).
t� ❑ I,awownerofihe yemp y g pcnution, NEW RESIDENTIAL ELECTR _S .F1'.
prsumm,nrm en ed oro wn omtheinole cont S'1'ORIIS 'TYPE CONSTRUCTION
y3— will dotheairm,andthe summons,is icamse Law
os rim apip ,toe(Sccan..as,of
pness
roperty
Profusions Cade:The vesthecmr's License Law docs not apply to an owncrof
grocery who builds or improves thereon,and who aces such work himselfmr through his
own employees,providW that each impmvementsvre not intended ornffcred forsnle.If, OCC.GROUP BES.UNITS
IrWever.me huildingurimpmvern i.e.sold withinmm ycarofcomplelam,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownernfthepmp y,eme clusivelycomrectingwithllnena CanlmntllrstO QTY. PLUMBING -R FEE FLOOU ZONE APN
consumer the pmjttt(See.7044,Business it Professions Cade:)The Cmumemre PERMIT ISSUANCE
License Law does not apply m an owne r o f prapery who bui Ida or im proves thereon,and
whocomrams forsuch projects with u contractor(s)licensed pnrsuanttothe Commnor's gLl'IiR DRAIN& ;N'I'�
License Lrov. — ' (: FEESUMMARY
❑ I atm exempt under Sec.' ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE :;S
SANITARY Y_N
t Uwner - Date DRAINS-I, RECF.II'T#
FLUOR,ROOF,AREA. O D
WORKMAN COMPENSATIONDECLARATIONSCHOOLTAX Y N
❑.Ihereby affirm thou have eceniL<ate of consent to self-insure,oramnifevm of RI3Cf;IPI'M
PI%TURES PER TRAP
Workers'Compensutionder this permit.
ifed copy thereof(Sec.JB00,LaM1CJ which PARK FLIT Y N
. s covers ell employhes under ibis permit. OAS EA.SYSTEM-I INC.40UTLET RI IS ION
Policy 4 BUILDING 1 ISION FEFS
Company GASEA,SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cel l ropy is ideal w with
the icyd. 1
❑ Certified copy is GlM with thecity inspection division. GREASHIINDUSTRL WASTE INTERCEPTOR GRADING THE ASn
CLiRfIFICATE OFE%f;MPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
mdsaecion med not he completed little permit is mmne hundred dollars($loo) SEWER-SANITARY-ST ORM EA.20017. ENERGY FEE
orlesa.)
I century that in the performunm ofthe work for whidt this Permit is issued,l shall WATER HEATER WNENT(ELECTR
not employ any person in any manner so aw to become subject to the Workers' PAID ZL1/1 Z 2 J
Compensation Lawsof Califomiw Data WATER SYSTENINRfATING Date Recciet4
N SeloApplies t
� M NOTICE TOAPPLICANT:IL Commerkingthiso'hCertificate fin Exemption,ode,'ouhould NEW RESIDENTIAL PLMFl. SUIT' TOTAL:
rn bcccure hwithcjcit mpy the Workers Goons or this
Permit onsotthe Laborevoked. moat
a h
forthwith comply with such provisions or permit shell be decmeJ revoked. BUILDING FEE IM
yQ CONSTRUCTION LENDING AGENCY SEISMIC TLE �f!
7-. 1 hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
r header's Name '— —^—• -
headersAarhess QTY. MECHANICAL PERMIT FEI3 PLUMBING FEE
U I certify that I have read this application and state than the above information is ' ` '
r1' L17 c rxt.I agree err comply with all city and county ordinances and state laws relating to. .PRRMIT ISSUANCE MECHANICAL FEE
F" building conatmmion.and herehyvvthorian represenutivesoflinkCity wenmruponthe CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MEC11.
(We)egme to save,indemnify and keep harmless the City of Cupertino against
IiaM1ilities,ju1gmenb,cfstsen e Se n hich may in vny way acc......inst iJ icy AIR HANDLING UNIT(TO 10,000 CFM)
in
wnseyuencn antic of his
AIR HANDLING UNIT(OVER 10,000 CFM)
Signatureo p e v vac or Dae EXLIAUST1100D(W/DI1CD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT;(TO II .0110 BTU) Date Receipt 4
Will the applicant or future buildi ng confessor a tom or handle haaurdous material HEA'L'ING UNIT(OVER 100,000 BTU) 'TOTAL:
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cole.Seninn 25532(e)1 No
Y. No PAN(SINGLE RESID)
❑ ' ❑
ISSUANCE DATE
i Will thi4pplieantorfuwmbuildingacupantuuequipmemordeviceswhichemit BOILER-COMP DHP OR 100,1100 BTU) }k
harardous air comsminants as defined by the Bay Amu Air Quality Mena emem
Distinct? 1� 7Y
8 BOILER-COMP(OVER'100,000 BTU) ,p
I
/ ❑'Yes 11 No NEW RF;SIDENI'IAL MGCH. r(?3
SQ.IT. Jy.�1993
+u ,l have read the;liicardous mamrids requiremems under Chapter 6.95 of the
Califomia Hcahh&,Sere ty Code,Sections 25505,25533 anti25534.1 understand that
ifthebaral of gdoandments which
must
the metiialissuanceof a Certificate
the CIII L/r'uVra 17Y17U
cupant of the rtquirements which man be met priman issuance of a Cenificam of
Occupancy.
Owner or amhorited agent Dam 'TOI'A h: ISSUED BY: ZNG
OFFICE