24837 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOItl ILIUM..EL8CI RICAL PLRMI I'NO.
BUILDING DIVISION APPLICATION/PERMIT 1ILUM1lING-MECDAN1CAL 24837
I Op� �
BUILDING PROJECT IDENTIFICAT4ION
BUI1L/DING ADDRESS: /` / a I l' +j ` SANITARY NO. APPLICATION suRiArrri AL.DATE
_RZ o �Cr L`4 'V ' UNIT' I.G1'p 7J .Z6-034 C
IWNERS NA 1E: PHONE: CONTRACTOR'S NAME: LIC NO:
6 G {s/!� N CONTROLa
r
=HITECT/ENGINEFJL 6 LIC NO: ADDRESS: El
CONTACT: PHONE: BUILDING PERMIT INFO -
' QTY.`'s1:tr'":.`Y.ELECTRIC PER_MIT:. .,. FCL:."„
J If!-7C /j� PERMRISSUANCE ��. d7 BILUG E1,ECT PLUMB Mb❑CII
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL l�
_y.Z Ihercbvaffnn that Iran licensed under provisions ofaamer9(commencing with JOB DESCRIPTION
X00 Section)OOOIof Division 3 of the B districts and Professions Cod,and my license is in pgLg n
-U full faceted affect. :: U T
x U�j UP T02W AMPS J
<Zm Date Class—Cmbr
n« Date Contractor 201-IOW AMPS
ARCHITECTS DECLARATION SQ.PT.FLOOR AREA S/SQ.R.
yZ OVER IOOO,AMPS • ��
N
I understand my plans shall he used as public records. JlV//7
Z-0 W SIGNS ELECTRICAL
Licensed Prossim
feal
1WUz
OWNER BUILDER DECLARATION SPECIAL CIRCUITMISC.
JiU 1 heathy .. m that 1 am eumpa Goat the cmntcan,Co License Law for to
.01`~° which mete asoa Simian comm Business eaa ave se.de o li h.or:Any city or county TEMP.METER OR POLE INST.
whim requiresapemit peconswn.pplic int for sudemolish,file
repairany umment
jYc) thatpoorhe its ismarres.also
purse requires theapplicantfor Co melees License
La stalemem POWER DEVICES
,<c) that he is licensed pursuammthe provisions of the COmmnors Licenxelsio Chapter
Y 9(mmmencing with Section 70(la ..'Division 3ofte Business and Professions Coda SWIMMING POOL ELECTRIC VALUATION
!_ or that he is exempt Ucmfrom and the basis for the alleged exemption.My violation of n
-ZQ Section 7031.5 by any applicant for a permit subjects the applicanno a civil penalty of OUTLETS-SWITCHES FIXTURES ' S y76,
arc than five It or droll...($500) ...JJJ (((
i= NEW BESIDE
ELECT? S .FT.
y_� n I.aowncroftcpromny.ormyamployeeswit wegesuteirsolecompcnxatim, Q STORIES TYPE CONSTRUCTION
3_ wil do thewmk.aWteswnurt isnoa tritendedoroffered forxlelsec.]OW,Busiracss / .
and Professions Cade:The Contractor's License Lew does not apply to an owner of t
n n
promny whatimidsor improves thereon,and whodossaueh work himselforthrough his ?
emplgecs.provided Nat such imProvementaarcnm intendedoroffered Tortola.IL
5CC.GpOUP RES.UNITS
howntr.tebuildingorimpmvementissmldwithinoneywofcomplctim.theower- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of -
' . ..e ..
'L APNs } thliceneAommamsm QTY.,.41PERMIT akx
at❑ Lazwnuoftpmpn). mexcIusivc1ycon ingwi
A o i?TC
mrai the propect(Sec.70,14.Besimss small Proreasiom Code:)The Contractors - —
License Law dm%not apply to an owner of property who builds or improves trumon.and PERMIT ISSUANCE
ho<ommasfm such project wile econvanur(s)licenxd pursuuntmthe Contracmr's - +- p
�]L,C4 taw. ALTER-DRAIN&VENT-WATER(EA) .�%'.•, ;, .�".FEE SUMMARY_Yj+,, i
We 1 an exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUT DE FE LS
SANITARY Y N
• ftECEIPrN
,wan, " Dam DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I Ihembyaffrmthatlhave.cenl5oteofconxnttoxlf-insum.macer ficateof FIXTURESPER TRAP RECEIPT.
"- .raters Cmmpensatim Insurance oracenifc0 copy tercof(SecJBW.Iab C.)whicM1 PARK FEE Y N
RECEIPT It
covert;ell employee's under this pewit. GAS-FA.SYSTEM-1 INC.4 OUTLETS
poli,N BUILDING DIVISION FEES
Compact) GAS-EA.SYSTEM-OVER4 LEA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Candied copy is fled wit the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPHON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becomplaed ifthe permit in for one hundred dollars SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perlomunce of to work for which this permit is issued,l shall WATER HEATER WNFM/ELECR
not employ any person in any manner so as to become subject to the Workers PAID
Z Compenxtionlawsof California. Dam WATER SYSTEM(IREATING Date Receipts
C) NOTICETOAPPLICANT:ILaftermaking,hit Canirw.n.f Eaemption,youshould NEW RESIDENTIAL PCMB. SQ.FT. TOTAL: /- r
^ become subject othe Workers Compcnxtion provisions of the Labor Cod,you must BUILDING FEE �7
fordwith comply wit I)!7 such provisions or this permit shall be deemed invoked. �, �J 1
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE f a L
1 hereby affirm that them is a construction lending agency for the performance of
O the _ '.- TOTAL- _ ELECTRIC FEE Z
c work for which s pernii is issued(Sec.JW].Civ.C.) a
Lenders Name 't4"� -- ! PLUMBING FEE
Lenders Address QTY. -MECHANICAL PERMIT FEE: .
U 1 certify that I have mad this application and state that the above information is -'`ay"t" d'' - MECHANICAL FEE
1 Corea.l agreemmmplywith all city and county ordineneaand stale laws mildingto PERMIT ISSUANCE
building construction.and hereby autodre representatives ofthiseity m enterupon the CONSTRUCTION TAX
Z movcmcmioned propcny for impaction purpose. ALTER OR ADD TO MECH.
Ewe)agree to save,indemnify and keep h:nndess the City of Cupertino agmina
Iiibilitie,judgments.c..mdespenxs which may many way aceraae.g.ina said City AIR HANDLING UNIT(TO 10.0X0 CFM)
tCFan consequence equegranting of this permit.
iF .�-nce of the AIR FIANDLING UNIT(OVER 10,fXp h11
t C.60 llj�tz
Sib\riffs oofffApplicanUComraaor Data EXHAUSTHOODLW/DUCT) PAID
i Date Receipt a
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO W."BTU)
S Will the applicant or future building occupant atom ler handle hsturdeas material HfiATING UNIT(OVER 100.00t,B'1'U) TOTAL, 1 �
y ss defined by to Cupenim Municipal Code.Chapter 9.12,and to Health and Safety
1 Coat Section 25532(.)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
Willtheapplicntorfmumbuilding«upantuxequlpmenturdeviceswhichemt HOICM.COMP(3HP OR IW.Mil BTU) "' e t.•1
. commus air contaminants as defned by the Bay Arra Air Quality Management BOILER-COMP(OVER 1 W.(100 BTU) 1 Sl
mrin?
❑Ye, ❑No NEW RESIDENTIAL MECH. SQ.FT. MAR
R 7 2 199'3
I have lead the harmonious manrials requirements under Chapter 6.95 of the `17F1I� .L 17 s7
Cabftmia Ilealth&Safety Code.Sections 25505.25533 and 3534. 1 understand tat( 1
ifthe huildingdoes not currently have a mount.that it is my responsibility to notify the VII f Uf VUf LFII IIVV
mcup.m of the requirements which most be met prim m issuance of.Cmifmte of
Occupancy.
Owner ler mdami'eed age- Drum TOTAL: ISSUED BY:
OFFICE