27278 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-I1LI1C UKICAI. PERMI'TNO.
CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 27278 7 O
BUII,DING DIVISION IIIIILIIING PROJECT IIIRN'riFICA'1'ION,;. I 1 O
BUILDING AUI�ig.1 � �� �� TO SANITARY NO. APPLICA'PION gUBMI'ITAL DATE
LOTN
W(N/N"l 2H,: PHONE Q3 CONTRACTORS LIC NO: 1 I�1�
C'S l N/C CONTROL.
C 1 ECI'A'.NG ER: LIC NO: ADD RES
Ca ttQ p
CONTACT: PHONE: -
QT'Y. ELECTRIC PP.RMIT'- FEE, BUILDING PERMIT INFO,
RLDG ELECTPLUMB MECH
PERMIT ISSUANCE El 13 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCE'S-RESIDENTIAL TOB DESCRIPTION
Qwz I herebyaffirm that l um l icensed unterpeovisseco,d Chaminit(commencingwith
4100 Section AXgO.f Division 3 of the Business and Profession Code,and my license is in PANELS
full force end effact. .
G� License Class Lic.p UPT02MAMN
yjm Dam C.mmte 201-1000AMPS
z0Eei ARCHITECTS DI C1ARATION OVER Imad AMPS - SQ.FT.FLOOR AREA EISQ.PT.
O Z..❑ 1 understand my plans shall be used as public records.
F�2 1'W SIGNS ELECTRICAL
Q<a€� Licensed Prefessional
a
OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaU I hereby affiraid
at I am exempt from the Commemra license Luw for the
Say f.11awingreawn(Section 9031,5,Business and Prefnsi.ns Code:Any city orcounty TEMP.METER OR POLE INST.
oi which"does a farmil to consmua,alter,improve,demob+h,or opium,xo-unure
a;!IQ;� priorro its issuance,also requires the applicant for such permit to file a signed statement POWERDEVICES IF
deal he is licensed pursuant o the provisions of the Convanors License Law(Chapter
a lr- 9(enmmencing with Section 7000)efDivision Jof the Businessmnd pruressions Cade SWIMMING POOL ELECTRIC
VALUATION
-,y
or that h7031.5 by therefrom and for
Permit subjects
Thedexcmant to Anyviolation of
1-.Ea< a alne its.five
othedicantforapermit subjens the applicant mxcivil penally of OUTLETS-SWI TCHPS-FIXTURES
"O 0 1.asotn rafthe hW11o11.m ycrapi
KK�� ❑ L.he mrs Othogrrtym,isa.mployed withwagesfor late
campensrlon, NEW RESIDENTIALELI3CIR _SQ.FT. -STORIES TYPE CONSTRUCJ'ION
q'3-� will doemwons.nollefoe Contra not is License La suffered not
applyt044,Boniness
and Professions Cale:The Contractors License Law does not apply to an owner of
propcny who bullas or improves thereon,and who does such work himselfor through his I. ��
ow n emre employees,provided that such improvements anot intended of offered far salOCC.GROUP RES.UNITS
e.IL
however,the hadding or improvement is sold withinnneyear ofcompledia,the owner- I 'Zl -T9TAL:
builder will have the burden ofproving that he did not build or improve for purpose of
sale.). Q is IT p " FLr£°,°. FLOOD ZONE APN
❑ 1,.n owner nftlre progeny,umexdmivNy<uno-ating wit hiianentimracmmo TY•'' y PLUMBING PER S
C.ntruct the Police,(Sec.](194,Holiness end Prefessions Cade:)The Contractor. N1
License Law does not apply loan ownerofpropeny whobuilds mimproves themonand PERMITI DANCE
who contractsfor such projects with aconbactor(s)licensed pan..am mine 1-o-wus ALTER (F.A) EESIIMMARY.-
License Low. ,
❑ 1 am exempt under Sec. ,B&P C for this reason
BACK FLOW PROTECT.DEVICE OUTSIDE : .SANITARY YN
Owner Date DRAINS-FL000.ROOFAREA,COND. RECEIPTM
, , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l havesceninemeoramsem to self-insure,...cenificme of FIXTURES-PL'R TRAP RECIiIPfp
Workera'Compensotion lnsumnce orecertifiN copy ntereof(See.J800,Iab CJwhich PARK FET? YN
covers all employee's under his permit. GAS-FA.SYS TEM-I INC. OUTLETS RECfIIPI'N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PGH
❑ Certified copy is hereby foadqual
❑ Certified copy is filed with he city inspection division. GREASEANDUSTRL WASTE.INTERCEPTOR GRADING FIiE
CERTIFICATEOF EXEMPT ION FROM WORKERS' GREASFTRAP SOILS PER
COMPENSATION INSURANCE
(This sectianneednm he completed ifthe gamut is forma hundred dollars(S100) SEWER-SANITARY-STORM EA.201 ENERGY I'EE
.r leas.)
I certify that in the performance of the work for which this permit is issued,Ishall WATER HEATER W/VENT/ELECfR
not employ any person in my manner so as to became subject to the WorkenT PAID -
z w
Compensation Los.f Culinerem. Dale WATER SYSTEMITRP.ATING Date Receipt#
O O Applicant
NOTICHI'O APPLICANT:If,Tom,making this Cenificam.f Exemption you should NEW RESIDENT(AL TIME. SQ.FT. TOTAL:
r VA Meomesubjecn.the Worker's ComPeated.p,wisionollhe labor Cade,you must
Forthwith comply with such provisions or this perrnil shall he eaemed revoked. BUILDING FEE
Wz
j~ CONSTRUCTION LENDING AGENCY SEISMIC M7B
•^� I hereby affirm That them is.construction lending agency for the Performance of
L) O the work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U. p leaders Name
t<ndere nedrenn Q7 Y,. MECHANICAL PLRMITl' FEH 1�y,;"< PLUMBING FEE
V 1 certify that 1 have rad this application and state that the move information Is _{ `" r•r` y'J' '*-''
OW., cornet. Iagreem comply with all city art cauntyordinancesand fore laws mlaling to PERMIT ISSUANCE. MECHANICAL FIiE
Ur
(n building comtrudion,and hereby audionse representatives ofthis city toeeer upon the CONSTRUCTION TAX
U above-mentioned property far inspection pupwus. ALTERORADDTOMECH.
(We)ugme a.save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs andexpcnus which may inany way occom agwnst said City AIR HANDLING UNIT(TO 10,000 CFM)
comm c of the grunting of .mil.
AIR HANDLING UNIT(OVER 10,000 CFM)
SWaddm.!Appliclm/C.mractor 'Dam EXHAUST HOOD(W/DUCPI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOO,IX1)BTU) 0
Date Rcccipt IT
Will the the Cupertino
ture Municipal
Cng ode,
Chapter 9,12,
and
IncentivesmaterialSafety HEATING UNIT(OVER IW,"BTU) TO
as defined by the Cupertino Municipal Cwle,Chnpmr Y.12,and the Health and Safety
Code,Sxti D Yes EI Na
25532(.)?
❑ VENTILATION FAN(SINGLE RESID)
Will the applicant on mem building aaeapxnww equipment an devices wren emit
BOILER-COMP OFT OR 100.000 BTU) ISSUANCE DATE
• haurdous air contaminants n defined by the Bay Area Air Quality Management BOILER-COW(OVER 100,000 BTU) P p I
Dismct? N
L
Yes ❑Nn NEW RESIDENTIAL MECH. SQ.PT
read the local materials requirements under Chapter 6.95 of the NOV 1 1994
e.Rh&Safety Codd,Sections 255(5,25533 and25534.Iunderstndthatg docs not currently have a mase,that it is my responsibility to notify she
the requiremets which must he met prior to issuance of a Certificate of
CITY Uq-h.racd agent Date ISSUED BY:
OFFICE