26681 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUIL. :-R11huff cti, ...z NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB"G-MECHANICAL. 26681 O 4
BUILDING PROJECT IDEN'I'IFICA}ION 6 6 O 1
BUILDINCG ADDRESS: SANITARY NO. APPLICATION suni,,ETTAL DATE
-71 Lord
OW LR NAME: PIIONE: CONT CTOR'S NAMIi: LIC NO:
/ Cr ��rp.� /GyP �/ r✓/ NIC CONTROL#
`ANfHITF.LT/ENGI�NF�.I'.R: IC NO: ADORESCY 'I �r'/IC• '/ '✓".(
(O, JJp l l rJG (a ❑
CONT PHONE:
`
.T
1 t'r - <BUILDING PERMIT INFO
pTY. 3 EI ECI'RIC PERMIT+ FEE
i�/p ,.��,s/� 3-22-72
At'AF^a'L GLH � ELECT PLUMB MECH
G/ L N/C — S2 z PERMIT ISSUANCE ❑ ❑ ❑
I.ICENSFDCONTRACTOR'SDIiCLARATION APPLIANCES-RESIDENTIAL
0442 I hereby affront hat Lam licensed underprovisions of Chapter9(commenting with LOB DESC
P400 Scaion70M)uf Division 3 nine Business and Professions Code,and an,license is in PANELS
�F�jj ca full force and effect
F;,GID License Class Z Lic.# IftIIP T02W AMPS
rnjy Dae Convacmr b 201-]"AMPS Vya ,Qrl�t
ZFOyZ ARCHITECTS DECfARsT10 OVER 1000AMP5 SQ.FT.FLOOR AREA $/SQ.FT.
0 Z_, I at my plana shall heated as puhlic records.
r ren SIGNS ELECTRICAL
Licensed Professional
�y Q OWNHR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ip�,O yF I hereby affirm tba 1 am exempt from the Cornmenr's License Law fm the
to 3 can following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
t_�g which requiter a Permit to construct,alter,improve,demolish.or repair any structue, POWER DEVICES
2.
W}M priorm its issuance,also requites the applicant forsuch permit m file a signed statement
y)W O0 that he is licensed parent to the Provisions of the Comreno/s License Law(Chapter p
dKo�' 9(commencing with Section 7(100)of Division 3 ofrhe Business and Professions Code) SWIMMING POOL PT FCrRIC )"f--^� �. -V IAA, , t
W—, coram he is exempt herefrom and the basis for the alleged exemption.Any violation of / �\S.1 I✓
F Q Section 7031.5 by any vpplicam for a permimsubject.the applicant OUTLETSo a civil penalty of -SWITCHES-FlXTURES J Y u
y� p nut mom than five handreddollars($500), iT
�y m ❑ I,usownerofthern n NEW RESIDENTIAL ELE= _SQ.Ff
p pc y,ormyempendeeswithwed forsaleirsole compensation, 'OR�t?$, T E CONS'I'RUCTION
y3� will dotheands: ]the lotmreimms not imendesnr Law does
apply tos70a4,Business �(l/O.
and Professions Cs or in tat Conthemons License Lew docs not apply w an owner of
pnrpenywhobuildsvi improvesthereon,and who does such work loroffe orthroughhis
wn employees,progtor improvement
sold within
ne estrafdmpletmd thema.lr, ,OCC.GROUP S.UNITS
howwer.the
ave the burden of eausinghat he id noncyea or improefo,theowe of TOTAL:
builder will have the harden of proving that he did ern build or improve for purpose of
sale.). 'QTY'
Q Yi -e .,
❑ Las ownerol the property, pTY:, s'� `P,LUMRING•I'ERMIT PEE ROOD ZUNI: APN
P R7W4,Business
ss and protrusio s Codesneed Contractors s`A� $+,y$�
construct the oesprojnot applSec.y
oano Business and protrusions builds
Code:)The Concon.ads
whoeao Lawdfrsuc upplymanmwnatotpmpmywhnhuildsnumprothe Cnrengvnd PERMIT ISSUANCE
whom Lmv.acts for suchpmjwtewithacontmemoHs)licenced porsuanuothe Conveanr's ALTER FEE SUMMARY
License Law. (IIA)
❑ I am exempt under Sea ,p&P C for this recon BACK ROW PROTECT.DEVICH 0 UTS1D FEES
SANITARY Y N
Owner Date— DRAINS-FLOOR,ROOF.AREA,COND. RF.CEIFI'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
W.
• Ihereby affirm that lhaveec<rrificem of cnmcnuo self-insure.orattrtifcam of FIXTURES-PER TRAP RECEIPT#
Workcrs'Compensvminn Insurance ora<ertifedropy thermf(Sec.3g00,LabCJ which PARK FEE YN_
us al l cmployee'.s undenhis permit. GAS-EA.SYSTEM-1 INC.4 0UTLETS RHCF.IPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYS'f'E OVER4(EA) PLANCHECK ME
EI Certified copy is heathy famished.
❑ Certified copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE SOILS FEE
('this section need not be completed ifthe permit is for one hundred dollen($[BE) SEWER-SANITARY-STORM EA.20011. ENERGY FEE
or Ices.)
I cenify that in the performance.fthe work for which this permit is issued,l snot] WATER HEATER WNENT/ELF.C'I'R
not employ any person in any maser so is,to become subject to the WorkersPAID
Compeneation"wsof Celifn.m. Date WATER SYSTENVIREATING Dm Receipt p
Q z Applicant
a
Z 0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
U) beemnesubjecuo the Wcrket's Compensation provisions ofthe Labor Code,you must
a 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I hereby affirm that hem is a construction lending agency for the performance of
O the work for which this permit is issued(Sec.3197,Civ.C.) TOTAL: ELECTRIC PEE
G. Lender's Name _ r -
O Lender's Address QTfSY� ?" °MECHANICAL PERMIT ' FEP. PLUMBING HE
I cenify toad I have mad this application and stem that me above information is '
correct.l agree to cormply with all city and county oninnncn,and nam MECHANICAL PERlaws relating to PERMIT ISSUANCE
F-' y building construction.and hereby authorize expremnmtiveso(this city to enter upon the
V Z above-mentioned pmpcny for inspection purposes. ALTER OR ADD'(O MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmems.ctaomd expenses which may inany way accrue againstamd City AIR HANDLING UNIT(TO 10,000 CFM)
in :e of tl1eyBrnting o � �i�/��
vim) AIR HANDLING UNIT(OVER Il1,OW CFM)
Signature of Applicurd/Contmcmr —T, peso EXHAUST GOOD(W/DUCq
- PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Bill BTU) Dam Ncecipt#
Will the applicant or future building occupant store or handle beurdous metrial HEATING UNIT(OVER 100,000 BI U)
TTA
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health ad nSafety
Code,Section e32(#)7
❑yea
El No VENTILATION FAN(SING LE RESID)
Will the npplieum or furore M1uilding occupanmse eyuipmem or devices which emit
BOILER-COMP(311P OR IW,OOIIB'fU) ISSUANCHDATIV
haurdous air comarrounis m defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,000BTU) Jilt
•
Danner?
11 Yee, ❑No NEW RBSIDENTIAI.MECN. SQ.IT. C�I'-` 1994
1 have mad the huzallons materials requirements under Chapter 6.95 of theI r(eVrr
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undersand that n
if the building does not currently have a tenant,mat itis my responsibility I.amity the /���(J
occupant of the requireniceds which most be mem prior to issuance of a Cermifc le of
Occupancy.
Owner or amhonscd agent Dam TOTAL: ISSUED BY:
OFFICE