27573 ,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-CLECPR PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 27573
C 7 O
BUIhDIN
O All RE55� BUILDING PROIF:C'i'IDEMI'IPICA'I'ION / TT / J
(f/ 85 `'rys� SANITARY NO. APfP'L�ICA9'ION SUBMITTALli
UA'l
L UNIT# LOT ` v� L—CIL,[
aabiOWNERS NAME: PHONE: ACTOR'S NAME: LIC NO: NIC CONTROUN 1 1
\RCIII'1'IiC171iNGINEIiR: LIC NO: RIiSS: - ❑
'ONTAM:
{ la- ELECTRIC PERMIT FEE BUILDING PERMIT INFO
G',
�y l y LDG ELECT PLUMB MECII
l7,inn ��QL GI 1 na7— � 1I PERMIT ISSUANCE
mthat[SEDCONam dunderpmvi Dnsof Ch ter9(]ON AppLIANCPS-RESIDENTIAL JOB DESCR�
p tY z.- lherehyaffmICENSEDCONTRA TORSxDECLChepter9(commencingwith
Oryx�" I on T(Kg))of Division J of the Business and Professions Calc,and my license is in ppNpUS
�ytSJE full tome unJjf t.
_—<z License Clw( Lick A 1 UPT02MAMPS
ore D -�Coutrucinr 201-1000 AMPS
H y ARCHITECTS DECLARATI SQ..F1 ORA AREA $/SQ.FT.
ZOy IunJcrsland my Piens eM1e116e used republic records. OVER IOOOAMPS
;OZ-0 6�
:�=5; SIGNS ELECTRICAL a
9 SSdk Licensed iks&salona]
tyee< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.OGFI affirm Nat am exempt front e ComvnrLicense Law rrr she
W 3 rn followingng mas mason.(Section 703 L5,Businessss thm
and Professions Coo de:Any city tacounty TEMP.MC'PER OR POLE INST.
which inquires a permit re conswa,alcor,improve.demolish,fi repair any swemre
$M}0 that he itsissuance,also pursuant
tothe
the visio s ofnre Co permit's Licefic signed(Cement POWER DEVICES
ea eG that he is licensed pursuant to the pm Division
of the Contractor's License Lew(Chapter SWIMMING POOL ELECTRIC
px,e LL.. 9(rnmmencmgwith Section iumi of Division JeRhe Rumnessand.Any ions Cade) VALUATION
m Selho e is 7031. bytrompt crcfromandrho basis fu bje Wlogeaoxemon to Any vlololion of �•
W �} notiorethanSbehundre dollarsS50q.itsubjectstheopplicennoecivilpenallyof OU3'LBTS-SWITCHES-FIXTURES 7 �
not more than rofhe mre ny,lormye 0).
K m ❑ I,esnwneroflhe n NEW RESIDPNTIAL ELECIR —SQ.fT.
props y,ormyemtendedwiNwed forsthe(Sec. 044,8 sines STORIT•S TYPE:CONSTRUCDON
W
3— will dothcwon Code:
The cture Contra tot's License
ice se Law dos not apply X1A4,Business
and Professions Cade:The Contractor's LilW o Low does not apply m an owner iof
s
._ PmpatY who buildsorimpruvoe lhacon,unA whodsae such work himselfonhrnugh his
(employees,provided that suchimprovemenu arenotimended oroffered foreale.IL OCC.GROUP NIS.UNITS
however,he buildings,improvement is sold wid irima,carofcompletion,the own,
builder will have the burden of proving that he did mar build or improve for pmr; sf
sale.).
r% ❑ 1.aewnerofihe property,am exclusively contracting withiicensed contractors m QTY., PLUMBING PERMIT FEE FI.GOD ZONE; APN
entrust the project(Seo.II144,Business and PRnfeasinus Cade:)The Gmtmelou's
License 1.awdmsnotapplytoanownerofproNnywhobuildsorimpmvesthemnn,and PERMIT ISSUANCE
who contrasts forsuch projects with acontmemr(s)licensed porsuannothe Convectors ALTER-DRAIN&VENT WATER PA
License law. (' ) FEESUMMARY
❑ I am exempt under Sec. 1&P C for this..,on BACK FLOW PROTECT.DEVICE TSIDF FEfi
SANTI'ARY YN
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. NEClln#
WORKMAN COMP I SATION DECLANATI N SCHOOLTAX Y
❑ Ihertby affirm ihatlM1ovea ifica¢nf esraunno ulGinsu ora cenifcam of
MIXTURES-PIiR TRAP RECEIPT#
W.flas'Campensazian lnsu cermet. ifcdcopy thercof(See.300,iab CJ which PARK ILL Y N
coven allemplayee'su this permit GAS-EA.SYSTEM- INC.4 OUTLETS :CEI #
Policy k BUI r DI SION FRES
Company -' GAS-EA.SYSTEM-OVER PLANCHECK
❑ Car fed copy is hereby fumishM.
❑ Ce fed copy is fled wi$h the city ins tion division. ORE- SE(NDUSTRL WASTE INTERCEPTOR
GRADI t
CERTIFICATE OF ER ' GREASE,TRAP 5011.5
CO F. NINSUR
s sectio ce dif for dr dollan($100) SEWER-SANITARY-S3'ORM FA.200F1'. ENERGY ifi
onn"I \ '
Ic nif oared 0tlf 6O mk for whirJe is .it a issued,l shall WATER HEAThR WNENT(ELECI'R
oat em ey,any n any m nna a to b( object to the Worker' PAID
I Comps anti((Law f elifomis ate WATER SYSTIiM/fREATING
O z Applic t IJate Ra N
Iz 0 NOTI r TO APPLICANT:IL after makin is Cenifica¢af Exemption,you should NEW RESIDPN'I IAL PLMB. SQ.FT. TOTAL:
.F becom suhjacnathe Worker's Compen con provisions of the labor Code,you most
� � foMwi h comply with such provisis r this penrdt shell be deemed revoked. BUILDING FEE
e z roll
CONS CTION LENDING AGENCY SEISMIC FEE ` O
^a I h rehyulfrmthett is aconstruminn lending agency for the performance of
V C) the work -'which the ,mit is issued(Sec.3097,Civ.C.) TOTAL: - ELECTRIC IPE
O ULender's No
Lender:Address QTY. MECIIANICALPERMIT FEE PLUMBING IEE
I certify NC I have mad this application end s...ha he naive information is MECHANICAL FF.F.
crooner. I agree to comply with all city and couray.ohnancesandxtate laws relating to PERMIT ISSUANCE MECHANICAL
building construction.and hemhyautaidu rcponsenratives ofihis city to enter upon the
V Z ahnve-mentioned property foo inspection purpmes. ALTERORAUDTOMECIL �� CONS]RUC1'ION TAX
(Wed agree to save,indemnify and keep hamdess the City of Cupertino against
Iiabiliticajudgmenls,convand expenses which may in any way acemeagainst said City AIN HANDLING UNIT(TO 10,000 CFM)
consequence of the gmndng of this permit.
in
AIR HANDLING UNIT(OVER IB,IIfkI CFM) -
ignamreo'Appli V raamr D c EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS16SCLOSURF. HEATING UNIT ITO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as marred by the Cala n ra,Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'I
1:1 Yea El No VENTILATION VAN(SINGLE RESID)
BOILER-COMP(3HP OR IM,000 BTU) ISSU6NCG DATE
Wills cit"liessumfImre buildingouhi
ecupunt uequiprtantordeviceswcherim �{'tia / py
ist,aP
infamous air comandnanis aw refund by the Bay Area Air Quality Management BOILER COMP 100,0000 ETU)
l 6/
❑Yee ❑No NEW RESIDENTIAL MECIL SQ.In, /sI� q�Ap
1 have and the hazardous materials requirements under Chapter 6.95 of the CII�L� �� Z99S
California Health @ Safety Cade,Sections 25505,25533 and 25534. 1 understand Nat L
Hors buiidingdues not comemly have n tcnam,that it is my responsibility m and fy the H`Up`
occupant of the requirements which must he met prior to issuance of a Cenifeme of
Occupancy.
Owner to aulhonmd agent Dam
ISSUEDH .
OFFICE I
,APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-CLECPR PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 27573
C 7 O
BUIhDIN
O All RE55� BUILDING PROIF:C'i'IDEMI'IPICA'I'ION / TT / J
(f/ 85 `'rys� SANITARY NO. APfP'L�ICA9'ION SUBMITTALli
UA'l
L UNIT# LOT ` v� L—CIL,[
aabiOWNERS NAME: PHONE: ACTOR'S NAME: LIC NO: NIC CONTROUN 1 1
\RCIII'1'IiC171iNGINEIiR: LIC NO: RIiSS: - ❑
'ONTAM:
{ la- ELECTRIC PERMIT FEE BUILDING PERMIT INFO
G',
�y l y LDG ELECT PLUMB MECII
l7,inn ��QL GI 1 na7— � 1I PERMIT ISSUANCE
mthat[SEDCONam dunderpmvi Dnsof Ch ter9(]ON AppLIANCPS-RESIDENTIAL JOB DESCR�
p tY z.- lherehyaffmICENSEDCONTRA TORSxDECLChepter9(commencingwith
Oryx�" I on T(Kg))of Division J of the Business and Professions Calc,and my license is in ppNpUS
�ytSJE full tome unJjf t.
_—<z License Clw( Lick A 1 UPT02MAMPS
ore D -�Coutrucinr 201-1000 AMPS
H y ARCHITECTS DECLARATI SQ..F1 ORA AREA $/SQ.FT.
ZOy IunJcrsland my Piens eM1e116e used republic records. OVER IOOOAMPS
;OZ-0 6�
:�=5; SIGNS ELECTRICAL a
9 SSdk Licensed iks&salona]
tyee< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0.OGFI affirm Nat am exempt front e ComvnrLicense Law rrr she
W 3 rn followingng mas mason.(Section 703 L5,Businessss thm
and Professions Coo de:Any city tacounty TEMP.MC'PER OR POLE INST.
which inquires a permit re conswa,alcor,improve.demolish,fi repair any swemre
$M}0 that he itsissuance,also pursuant
tothe
the visio s ofnre Co permit's Licefic signed(Cement POWER DEVICES
ea eG that he is licensed pursuant to the pm Division
of the Contractor's License Lew(Chapter SWIMMING POOL ELECTRIC
px,e LL.. 9(rnmmencmgwith Section iumi of Division JeRhe Rumnessand.Any ions Cade) VALUATION
m Selho e is 7031. bytrompt crcfromandrho basis fu bje Wlogeaoxemon to Any vlololion of �•
W �} notiorethanSbehundre dollarsS50q.itsubjectstheopplicennoecivilpenallyof OU3'LBTS-SWITCHES-FIXTURES 7 �
not more than rofhe mre ny,lormye 0).
K m ❑ I,esnwneroflhe n NEW RESIDPNTIAL ELECIR —SQ.fT.
props y,ormyemtendedwiNwed forsthe(Sec. 044,8 sines STORIT•S TYPE:CONSTRUCDON
W
3— will dothcwon Code:
The cture Contra tot's License
ice se Law dos not apply X1A4,Business
and Professions Cade:The Contractor's LilW o Low does not apply m an owner iof
s
._ PmpatY who buildsorimpruvoe lhacon,unA whodsae such work himselfonhrnugh his
(employees,provided that suchimprovemenu arenotimended oroffered foreale.IL OCC.GROUP NIS.UNITS
however,he buildings,improvement is sold wid irima,carofcompletion,the own,
builder will have the burden of proving that he did mar build or improve for pmr; sf
sale.).
r% ❑ 1.aewnerofihe property,am exclusively contracting withiicensed contractors m QTY., PLUMBING PERMIT FEE FI.GOD ZONE; APN
entrust the project(Seo.II144,Business and PRnfeasinus Cade:)The Gmtmelou's
License 1.awdmsnotapplytoanownerofproNnywhobuildsorimpmvesthemnn,and PERMIT ISSUANCE
who contrasts forsuch projects with acontmemr(s)licensed porsuannothe Convectors ALTER-DRAIN&VENT WATER PA
License law. (' ) FEESUMMARY
❑ I am exempt under Sec. 1&P C for this..,on BACK FLOW PROTECT.DEVICE TSIDF FEfi
SANTI'ARY YN
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. NEClln#
WORKMAN COMP I SATION DECLANATI N SCHOOLTAX Y
❑ Ihertby affirm ihatlM1ovea ifica¢nf esraunno ulGinsu ora cenifcam of
MIXTURES-PIiR TRAP RECEIPT#
W.flas'Campensazian lnsu cermet. ifcdcopy thercof(See.300,iab CJ which PARK ILL Y N
coven allemplayee'su this permit GAS-EA.SYSTEM- INC.4 OUTLETS :CEI #
Policy k BUI r DI SION FRES
Company -' GAS-EA.SYSTEM-OVER PLANCHECK
❑ Car fed copy is hereby fumishM.
❑ Ce fed copy is fled wi$h the city ins tion division. ORE- SE(NDUSTRL WASTE INTERCEPTOR
GRADI t
CERTIFICATE OF ER ' GREASE,TRAP 5011.5
CO F. NINSUR
s sectio ce dif for dr dollan($100) SEWER-SANITARY-S3'ORM FA.200F1'. ENERGY ifi
onn"I \ '
Ic nif oared 0tlf 6O mk for whirJe is .it a issued,l shall WATER HEAThR WNENT(ELECI'R
oat em ey,any n any m nna a to b( object to the Worker' PAID
I Comps anti((Law f elifomis ate WATER SYSTIiM/fREATING
O z Applic t IJate Ra N
Iz 0 NOTI r TO APPLICANT:IL after makin is Cenifica¢af Exemption,you should NEW RESIDPN'I IAL PLMB. SQ.FT. TOTAL:
.F becom suhjacnathe Worker's Compen con provisions of the labor Code,you most
� � foMwi h comply with such provisis r this penrdt shell be deemed revoked. BUILDING FEE
e z roll
CONS CTION LENDING AGENCY SEISMIC FEE ` O
^a I h rehyulfrmthett is aconstruminn lending agency for the performance of
V C) the work -'which the ,mit is issued(Sec.3097,Civ.C.) TOTAL: - ELECTRIC IPE
O ULender's No
Lender:Address QTY. MECIIANICALPERMIT FEE PLUMBING IEE
I certify NC I have mad this application end s...ha he naive information is MECHANICAL FF.F.
crooner. I agree to comply with all city and couray.ohnancesandxtate laws relating to PERMIT ISSUANCE MECHANICAL
building construction.and hemhyautaidu rcponsenratives ofihis city to enter upon the
V Z ahnve-mentioned property foo inspection purpmes. ALTERORAUDTOMECIL �� CONS]RUC1'ION TAX
(Wed agree to save,indemnify and keep hamdess the City of Cupertino against
Iiabiliticajudgmenls,convand expenses which may in any way acemeagainst said City AIN HANDLING UNIT(TO 10,000 CFM)
consequence of the gmndng of this permit.
in
AIR HANDLING UNIT(OVER IB,IIfkI CFM) -
ignamreo'Appli V raamr D c EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS16SCLOSURF. HEATING UNIT ITO 100,000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as marred by the Cala n ra,Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'I
1:1 Yea El No VENTILATION VAN(SINGLE RESID)
BOILER-COMP(3HP OR IM,000 BTU) ISSU6NCG DATE
Wills cit"liessumfImre buildingouhi
ecupunt uequiprtantordeviceswcherim �{'tia / py
ist,aP
infamous air comandnanis aw refund by the Bay Area Air Quality Management BOILER COMP 100,0000 ETU)
l 6/
❑Yee ❑No NEW RESIDENTIAL MECIL SQ.In, /sI� q�Ap
1 have and the hazardous materials requirements under Chapter 6.95 of the CII�L� �� Z99S
California Health @ Safety Cade,Sections 25505,25533 and 25534. 1 understand Nat L
Hors buiidingdues not comemly have n tcnam,that it is my responsibility m and fy the H`Up`
occupant of the requirements which must he met prior to issuance of a Cenifeme of
Occupancy.
Owner to aulhonmd agent Dam
ISSUEDH .
OFFICE I