27321 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
7. f� q
1-- . ..1;BUILDINGPROJECTIDENTIFICATION;;;a,,',,y - G
ILDING ADD732 -1
RESS: SANITARY NO. APPLICATION SUBMITTAL DAT
NN5F923 SaL_LINti 20� �/'� �
00 1 V N!3MEj �y Pt10N': �� CONTRACTOR'S NAME: LOT p LIC NO: I
' I S/C CONTROL
ARCHITECT/ENGINEER: IC NO: I A DRESS: ❑
CONTACT: PHONE: VV,�. ..n :y,.
QTY..�',a NSaI ELECTRIC PERMITy`� t{ ;'t FEE 2 'F x r.'''`t''BUI DING PERMIT INFO
wF ILA' rr+snry.t+exesuw .e•xsy: t -s,:fle^:.v "'ii BLQG ELEg PLUMB
PERMIT ISSUANCE ' l�fClt
LICENSED CONTRACTOR'S DECLARATION gppL1ANCE5-RESIDENTIAL
C=Z I hereby affirm that l am licensed underpmvisioneafChapur9(commencing with IDB DESCRIPTION
�st 00 Scene.7000),f Division 3of the Business and Rvfessions Code,and my license isin pgryELg ._—
C U F roll force and effete
F ZUe License Class Lir, UP TO 200 AMPS
mjy Date Coem Mr 201-1000 AMPS
Zo,— ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $,sQ.PT.
O Z—G I undmmnd my plans shall be used as public..Ms.
G j M d Licensed Padessional SIGNS ELECTRICAL
iL'e+U
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xOaF 1 hereby affirm Nat I um exempt from the Convectors License law for the
W!
following mason.(Section]03).3.Business and Profcamm;Code:My city mount TEMP.METER OR POLE FIST.
y, which requires o Penni[to conswct,alter,improve,demolish,m repair any su mum
.WYE priorm its issuance,also requires the applicant formch pemdtto file a sign<dsmtement POWER DEVICES
a=<0
a<Os ohm he is licensed pursunn,a the provisions of the Compactor's License taw(Chapter
xmLL 9(commencing with Section'/000)of Division Sof the Basince.and Profession Cade) SWIMMING POOL ELECTRIC VALUATION
m—m or that he is exempt herefrom and the basis for The alleged exemption.My violation of
FZQ Section 7011.3 by any applicant for a permit subjects the applicant u a civil penury of OUTLETS-SWITCHES-FIXTURES
S Q not more Nan Eve hundred dollars(8500).
�Fm ❑ T,asowneraftheProperty,ormyemployeeswiNwagesmtheirsolecompe..tion, NEW RESIDENTIALELECfR _SQ.FT.
a3— will do the work,and the aoucmm is notrebound m offered far ade(Sec.1044,Business STORIES TYPE CONSTRUCTIO'
and Professions Cade:The Committees License Law does not apply to an owner of
property whobuildsorimproves Merton,andwhodeassuch workhimselforthrough his
awn employees,provided tha[such impmvemcn%mnotinwndedmofferedforsle.If. OCC.GROUP RES.UNITS
however,the building or improvement is said within one yemofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
at
❑ I,asownerof the propetY.amexolusmvelyconvacong with licensed con one d -PLUMBING PERMIT¢ fi $ FEE FLOODZONE ppry
nwct The pricier,(Sec.1Ba4,Business amu Profession Cade:)The C vecmrs
License Law does notzpply to an owneropeopeny whobuddsorim)Zzd mon,and z PERMIT v� CE
whaconuncmfor such projncta with acontractm(s)licensed pursuer tor, onVac,or'x
- -"
License Law. AI-TER.DRAIN&V MIR(EAT :, ;._. .- +:�i:"G FEE SUMMARY:'>4,:-',,".rnr:
❑ 1 am exempt under Sec. ,B&P C(o Nis mason BACK FLOW PROTECT.DEVICE UTSID S
Owner SANITARY Y_N
• Dete DRAINS-FLOOR.ROOF, ONO. RECEIPIN
WORKMAN COMPENSATION SwfT nnntCLARATION SCHOOLTAX Y_N_
❑ Iherebyaffotion[DsumccwzcE [ conffi f(SMure,ma 'feamof FIXTURES PE RECEIPLM
Wvers 4 Compbnsa[ion lnsuence macemfedcopy thermf(Sec.3800,00 C.)which PARK FEE Y N
cove all emplayee'a under this permit RECEIPf g
Policyp GAS-EA.SY -I INC. OUTLETS
Company BUILDING DIVISIO FEES
GAS-EA./S -0V 6 EA)
❑ Cenifed coPY a hereby fumiahetl. ( PLANCfECK FEE
PY is filed with the city inpation division. GREASEBNDUS WA INTERCEPTO GRADING FEE
CERTIFICATE OF EST ON FR OM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
(This section need nmbe completed ifthe perdt is fm one hundred o11an(81007 SEWER-S ARY T RM EA.20017. ENERGY FEE
orless)
"'Y
Nat in NepMormaroce of the work forwhich Nix pard sbaned.I shell Wq RWNENT/ELECIR
not employ any person in any tamer so ss m become subject a the Workers' PAID
z Compensation Lawsof Califemis Date WATER SYSTEM/IREATING
Applicant Date Rmeiptg
z NOTICE TO APPLICANT.If.after making this Certificate Of Eaemptia , .should NEWRESIDENTTALPLMfL SQ. .TOTAL
f'"' .�-i become subjx[,oth,Workers Compenssdan provision of Ne Lahr Code,y ass
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDLNG F7:E
pW, CONSTRUCDONLENDMOAGENCY SEISMIC FEE
Z) Z I hnmby affirm that them re aconvo
svtion lending agency fm the perfmmance of
U O the work for which This permit is ,an.(Soc.Df19T,Civ.C.) ELECTRIC FEE
LI. Lenders Name uIt{ +s a. - 1 se, sass' reatimsee Map
O Lenders Address QTY "�-*y „MECHANICAL PERWr' `FEE s PLUMBING
I cbnify the I have rtad This apn astet,
plicationd that The above information is
F correct.l agree m comply with of city and county ouinmma and sem laws acating ed PERMIT ISSUANCE J MECHANICAL FEE
_ C4 building construction.and hereby auNmize rtpmsenudva ufthisciry to enter upon the
U z above-reef ned property for tax title s.n pompouALTERORADDTOMECH. CONSTRULTIONTAX
(We gree ea save,indcaify and keep harmless the City of Cupertino against
limiliti dgmrnu,cosmandexpenxswhich may in any way ucemeagains,sold Ciry AIR HANDLING UNIT LTO 10,000 CFM)
in can nee of the granting of this permit
1 AIR HANDLING IMIT(OVER 10,000 CFM)
Signature of Mplican not a, EXHAUST HOOD(W/DUCD
PAID
ARDO MATERIALS DISCLOSURE. HEATING UNIT(TO 100,000 B11J) Dam Rmeipt4
Wil I the applicant or future building occupant stare or handle hazmdous material
as defined by the Cupertino Mmanipai Care.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100P00 BTU) Q
Code,Section 25532(a)1
❑Yes El No VENTILATION PAN SINGLE RESID)
• Will,air co icaeoents as defined by the
Arm
ualityc Manage ant
BOILER-COMP QHP OR 100,0110 BTU) ISSUANCE DA
hanudom air comainums as defined by the Boy Ara Air Quality Management BOILER-COMP(OVER 100AOO BTU)
District'
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.PT. A
I have read the hardous materials requirements under Chapter 6.95 of the D
az
California Health&Safety Code.Sections 25505.25533 and 25534, 1undersmnd that Nov
ifcupant dingdoes
quiremnts ly have a which
that it my responsibility oto notify the 9 1994
�
occupant of the requirements which mus be son poor m issuance of a Cenificote of �V 9 n
(kcuPon<y. � - ff
.il v
Owner ar archon ed agent Date
" ISBUED BY:
OFFICE