23271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Project Identification I PERMIT NO.
Building Address: 2327 a"(2 7
e1 .lK1
cmc: one:
I7✓' QC/IT' c0_%Z)-11a3 CITY OF CUPERTINO-BUILDING DIVISION a /�� d•1
C .a aces: Lic.N. APPLICATION / PERMIT L/— O�
rchltect/En r. BUILDINGEIECTRICALPLUMBINGMECHAMCAL CATEGORY COO NTROL M
ghee Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Acidneee: PLUMB MELH
-
LICENSED CONTRACTOR'S DECLARATION PFRMITISSUANCE El ❑ 1:1
I Fsh Sedi flmnthat)of Di lbm3ofunder tr andmfC otsCode, menc- APPWANCESRESIDENML . JOB DESCRB'I'ION
Ijore j5ec11on20W)o(Dlvfect. fthe Buelvssand ProfeWonsCade,mdrm a
Iimna{see/isCl�:n to d effect. PANES /.�t/� ,�(��).�j. }''
Limnf- . LIc.N / - // �/,4� f�N-/ ' )/
Date Conlrad.
ARCHITE SDECLARATION '- / 201-1000 AMPS
�pu000 v
Iundentand my pbplanse}ushallbe used an publlcremrds. OVER 10D0 AMPS IN NAR 5/SQ.FC.
Licensed Pmfemlol SIGNS ELECTRICAL
OWNERexNLDER DECLARATION SPECIAL CIRCUIIT/MISC T E R
0 9 owing reason.arm that I Sectio 7 31.5,Bxempt froess a Contractors siCed:law fm the
oo pp =nty hichrL (Sectape7 tW Bushes and Professions
emie hnytltyor
09- following
.oytty hlchpd t.iapertN ,.Iso ruc;altheaphmntfmoWh,orndt to TEMP.MEITAORI'OLE INST.
`a 7 any strigned tatemelta Wt he se licensqubeatheappBvnt torsuchpeof he POWER DEVICES
O floc a signed statement that he b r 9(co d pursuant it the proal ions of Me
DATE
Contractor's License Lw(Chapter9(commentlng with Section p"herefo(Divi. SWIMMING IDOL ELECTRIC VALUATION
��1 sbn basis fo thee alleged dexemption.Any)violation f Seem)(therefrom and
<
the basis forihermitobjects
n.applicant
Anyviolationtoladvi ofnalty oZ03L5byany OUTLETSSWITCHESFIXTURES (��
app(cand(oraperm($500sets the epplkmttoatlWl penalty
ofnm nnrethan ( a/
five 1,as o nerdelof the pr. NEW REEDENTIAL ELECTR SQ.FT SMRIES TYPE CONSTRUCTION
�n ❑I,asowneroftheproperty,orhesemployees withwagn r their sets
compensation,,wifldoBuslethe workand ions C clam lerwtIntended orofferedLaw q
sale(Sec.apply
to an owner suW Pro(mbv Cod e:The uilds or impairs throve Law
S$ does not applybant.lufproperty his
nemplrlmproovidennes thatand such OCC.GROIIP RM UMTS
who due.
ments sorkhlmse ded oroughed owae.If,ho erpr,theb ildingor
Improvements lntenomyearofcmpie eNtf,h er-buflderwill ve TOTAL:
Improvement bmld within ovyearo(complettan,the owner-bu0derw111 have
the burden of proving that he did not bund or improve fee purpose cleats.). QTY. PLUMBING PERMIT FEE
LI FLOOD ZONE APN
L as owner tr the property,am.70"Business
contracting with licensed PERMIT ISSUANCE
TheconContreve mnstmtlthe project(Sec.apply
Bushesand of property
Code:
The Contravene.Improves
tissue Lw dace not apply tct an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or Imprmes thrown,and who contracts !m each p.oJecta with a FEE SUMMARY
cffictm(U Bmmed pursuant to the ContraRors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec 8&P C for this mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Ownm - Date RECEPTN
ORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCI{pOL TAX Y N
(hereby aftlrtn that I have a mrllRmle of consent to self-Marc,m a RECEIPT N
cert(Ivteof Workere'Compematlonly mnmwamdifiedmpytheteof(Sec.
3800IAb C.) S E
GAA.SYSTFM•1 WC.40UTLE1'S PARK FEE Y N
,
Polity N_ 07��.3 RFiCEPfIf
Com an�—�� 6 (J GAS F.A.SYSFEM.OVER4(EA)nifie - BUILDING DIVISION FEES
r;PWIIVd copy b hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ed copy is filedhere with the tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEINER-SANIq.ARY-SroRM EA 200Fl. Dale Recei t#
(Thlesectlon need not becompleted tithe permit b forov hundred dollars
($100 or less.) WATERHEATFR W/VENT/E.ECTR ENERGYFEE Y N
I certify that In the pedamunce of the work forwhlch this permit tattooed,
I shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workerc'Compensation Lwsof C.IIf.mh.Date PAID
Z NOTICE
E ece
Date Rl t#
O NOIICE TO APPLICANT-.If,after king this CertRWte of Exemption,you NEW RESIDENTIAL PLMB. SQFI'.
should become subject to the Workers'Compewtlon provisions of the Labor TOTAL:
cc W Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
�e
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d O Ihereby.fthe work for
w there bamnswctssued lending 15m. agencyfor the pedomt ELECTRIC FEE
0 Z Lender the workforwNch this permit is blued(Sm.3097,Civ.C3 TOTAL:
L) O- Lender,Name PLUMBING FEE
IL L) ender',Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imect.I agree haH ha compl WepaRcatlan do county
ordinances
rdi a cess dmateldon
1 bmrrectobuilding camplywlth all ndherbyauhorixe representatives
oftws PERMIT ISSUANCE FEES PAID:
} rebtlog oenteruponthe
e hem-menti edpropauthorize reprexnpurposo(tW
HN cit (Wr)aeree to the,indemnify an d property for Inspection of Cus. ALTER OR ADD TO MEC(.
? (We).gree to save,Indemnify an d}pep esrMen the City al Cu accrue Date RSO t#
V
against said City,judgmequencetof...the
expenses wMchrvyin anywayacave AIR HANDLING UNIT ITO IO,OWCFM) SUBTOTAL:
against said City In consequence of tM granting at this permit.. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CEM)
Signature of Applicant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appRvnl or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
}Ic❑atth and Safety Code,Sect 32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAC.
L: N
WlBlhe a pplimnt or tumbullding occupant use equipment ordevims VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which em(havrdoua ,"nota vnls as defined by the Bay Area Air p�
Quality Management DbW BOILER-COMP OM'OR100,000 BTU) B N
4 Yes o
havereadthehaza ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. 1
NEW RESIDENTIAL MECH. SQ.Ff APR 27 1992
and ' and that l(thc building does not mmen(ly eatenanl,that ltbmy
rd bllity to notify the ntof he q.u. is which must be rrcl
pot Lssuance ,Cert f p .!.I�¢�-r��' CITY Ur GUrenw�
tier or authorized agentl— Data ISSUED B �
TOTAL:
OFFICE COPY