27781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO UUILDING,
M,
v , PERMIT NO. __ -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
yyCart BUILDING PROJECT IDENTI -
TO[[DING SANITARY NO. APPLICATIONSUBMITTALDAT
C
A UNIT# Loll
—�
O NERS NAME: 11 ^^I. , PHONE: CO AC MC: L C NO:
Qw' E WW N/C 7 CONTROL/#/#
r�CHG Cl/ N V IIA -'1895y AUll S: It i 4!
1ONTncr: Y-1 #�;Y R'al+ va y s"2'+�,'a- „ BUIISDING PERMIT INFO:
0.L4- HAproiA 19 10”:
j[o �T�Ya;
BLDG ELECTPLUMB MF.CjI
PERMIT ISSUANCE �I ) ❑ Qk
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ILEI epi
OW CG 2, Iherebya firm thaH emlicensed underprovisions mf Cheprcr9(commencingwin - JOB DESCRIPTION
F+OO fu0xfn9andof iom3oftheBusinessan Cade dm I'renseisin PANELS R -
y af
L'tensa Clvss— 'Lonrzector � 201UP TOI OOOAMP9S - • A�D � �
r-n7z. ARCHITECT'SDECLARATION SQ.FT.FLOOR AREA
c�$/ FT.
,
j��0 1 understand my plans shall be used m poblic records. OVER 1000 AMPS �� � � a a•SQ.
SIGNS ELECTRICAL
.] Lmensed Pratessr0nal Z7 .
< OWNER-BUILD from,
DECLARATION SPECIAL CIRCUIT/MISC. I
KOp,F 1 heremby affirthm I am exempt from the Convector's License Law for the
B 3 4 m following reason.(Section 703 1.5,Business and Professions Cade:Any city or county TEMP,METER OR POLE INST.
' which requires n permit m constm , ,improve,demolish,or repair any structure
3a� prior wits issuance,also rondo, eapplt at for such permit to file a signed statement POWER DEVICES
�p mhat he is licemed pursuam a, a pmvtsion of the Comrnctoi s License Law(Chapter
LV,
a 9(commeneing with Seetlo 000).f DivismO 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC p[yl
„y orthathelsexempthemf mandlhebasisfor a alleged exemption.Any violation of AD VALUATI
M
Hyo Section903L5byany plicamforapevnitsub rstheapplican uirtuvilpenaltyof UTLETS-SWITCHES-FIXTURES �/" (/
❑ not more than five dred dollars($500).
pPo ❑ I,as owner eprofeny,orm am to easwit we NEW RESIDENTIAL ELECTR _SQ.F7. TYPE CONSTRUCT ION
y p Y drortaily(Silec0mpensafi0n, S DRIES
a wllldoge ,CNEt srmruremyym' ended oro dr ore t apply
Business
and Profs ons Code:Tpn Conuamors Lioene Law not apply m an owner of
proper ha builds or improvestM1ercon,� d h mrk himselfonlv0ughhis
,umarn I.,,,providedlhatsuchi sarenotnte edorofferedhersale.If, OCC.GROUP RES.UNITS
however,he building or im o dwithinone o complanumtheownerry
builder wi have the burde g thm he did no ild or improve for purpose of $ L' 1�
❑ Iasown ofthe t am xclusivel trngin TY� PLUMBING PERMIT 5: 0 g t#meg e FLOOD ZONE qpN
PraFxrY Y ty, codec)The Connector's
Q gs##a vy,ari�J Fza ' =,e: aRsESit
onerse the p 'at(Sac,904 , y who build Code:)rea Cemon,add who
etapplymanawner, pent'whnsedpsmrmnprome Comma,
and PERMIT ISSUANCE
who ommw.fors hprojaa wmthaPo acmr(s)liansed purs0ennotha Convaror's
IJcense Lew. ALTER-GRAIN&VENT-WATER(EA) drEi'^nn Y}- xA ;
u"NF�paT>Tr:w"PER SUINM1,ES
❑ I am exempt un r Sec. ,B&P C for this rcamn BACK FLOW PROTCCT.DEVICE UTSIU FEP.S
OwnerSANITARY Y_N
Dem DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT'#
WORK COMPENSATION DECLARATION SCHOOLTAX Y__N
❑ Thereby affirm that l have a cenificam ofconant to self-insure,ora cenificam of FIXTURES-PCR TRAP RECGIPf#
octets'employee'.code,this erruff. ifiedcopy thereof(Sa.3g00,LebCJ which PARK FEE Y__N__
Polus all employee's under this permit.
Policy N GAS-&i.SYSTEM-I INC.4 OUTLETS RECEIPT*
Company
BUILDING DIVISION FEES
4(EA)L
GAS-EA.SYSTEM-OYER R
❑ Certified ed.copy is hereby famishPLANCHGCK FEE
❑ Cenifiedcm filedwithfiecit
PY Ie Yinspecti0 division:.- ^^-^"'^^'T '
�,y, GREASE/INDUSTRL WASTEyYgIERCEPTOR GRADING FEE DO
CERTIFICATE OF EXEMPTION FROM WORKERS' ASE ! SOILS FEE
COMPENSATION INSU CE ww BQ
(Thissationnad not becompleredifthepermi sfar�f sutNiA Y-STORM EA.20017. ENERGY FEE �n
muss.) r !!!!ll��`��` G(J
Icenify that in the pertommnce of We wart for hich petmitmsmalted(Ih W E q NENT/ELIiCTR
not employ any parson many warmer so est tO comeGjeci to therk�o a PAID
Compensation Luwsof Califomie. Date W R YS�
Applicant TING '.k D.IF Receipt#
NOTICE TO APPLICANT:IL alter making rhutCenili I of ExFmp(iogyoo should L P_ �_SQ.PT.
1
V) become subject to the Worker's Compensation° visio�s of the Labor Code,you must TO'T �'
forthwith comply with such drovieions or this penrdts lbedeemedrcv0ked. AA
' BUILDING FEE B O
0.,
� A CONSTRUCTION LENDMGAOCNCY:'+^^•^""°"'s"� SEISMIC FEE #
Z thereby affirm that them is a omearuction lending agency far e performance of
O the work for which this permit is issued(Sec.309'/,Civ.C.) TOTAL: ELECTR
Lenders Name �$$ s !q
Leaders Address Y9... dq'FEE E'aA
U QTI,',, NfEC11AN1GL4P5RM1TS;dd#a 1 i � % i PLUMED
1 certify Ther I have read this epplicntimn and emm Wm the above infmrmahon rs
b W correct.Iegrcemcomply with all city and county 0rdinanae and state laws reletin t' p'
PERMIT ISSUANCE
MECHANICAL FEE
buildingconstruction,and herebymbmrxereprrenmfivea opsis city menter�pon the
Z
above-mentioned pr0peny for inspection purposes. ALTER OR ADD TO MF.CH. CONSTRUCTION TAX
(Wa)agree m save,indemnity and keep hertnleas Ne City Cu loo against
lixbilitics.judgments,costs end expenses which may' anyway cerua 'd ity ANGLING UNIT(TO 10,000 CFM)
in c0nsey it ing of this permit.
HANDLWG UNIT(OVER 1U,000 CPM)
gnrure of Affousawmarecuor A Date EXHAUST HO)D(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store nr handle hazmdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Ilaahh and Safety HEATING UNIT(OVER 100,000 BTU)
Cade,Section 25532(e)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
WRI theappllcantorfnum building Occupant useequlpmentordeviceswhichemit BOILER-COMP CHP OR 100,000 BTU) g�qISSUAN DATE
hazardous air confirmation,as defined by the Bny Arc.Air Quality Management
snip? BOILER-COMP(OVER 100003 B'TU) r, -4 . p1
V
❑Yes ❑No
NEW RESIDENTIAL MECH.—SQ,EL
I have read the hazardous materials requirements under Chapter 6,95 of the - U� go 199
Glifomla Heald,&Safety Code,Sermons 25505,25533 and 25534. I understand that 4J
if the building does not currently have a tenant,that cot is my issuance
of a e notify the {A
capon,of the requirements which must be met prior to issuance of a Certificate mf
Occupancy.
Owneror..thinned agent Dme ISSUED BY:
OFFICE ;