27472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING-ELECI HICAL PERMIT NO. A /�
APPIACATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION
BUTLDINGPHOJF.CI IDEN'T2 7 4 7-/
'IFICATION 1 4 1 L
NDIMING ADDRESS: SANITARY NO. APPLLIICATION SUBMITTALD/ATB
UNIT# LOT#
S N41`7.:_ PHONE: gGKIBACTOIll NA LIC NO-
N/C CONTROL
RCHITIiCT NGI F.ER: LIC NO: E 40 1- 11 6ZZ74 1❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BO ELO PLUMB MOH
PERMIT ISSUANCE (dry
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
mmz Ihereby affireathat l am licensed under provisionsm Cbtner9(commencing with
�i100 Section 7000)nf Sof the��//Business and Code.end my license is in PANELS W,»
full nee Candy 1
Z License -it c,p UPT02MAMPS
m¢y Dale Camracon 201-1000 AMPS
Z0!,z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA SISQ.FT.
0Z-0 I undersmnd my plws shall teused as public records.
re,y W SIGNS ELECTRICAL ..
License)Professional
�WG' OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0e. 1 hereby tiffirm rho I am exempt from the C.M.0 is License Law for the
w3LLco following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE.INST.
F:&OS which regdres a permit to construct,alter,irepmvq derminh,or repair any structure
WY7 prior m its issuance,also requires theappiicant for such Permit file a signed statement POWER DEVICES
<0 a_a O Nm he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aLkda�' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is exempt therefrom and the osis for the alleged exemption,Any violation of OUTLETS-SWITCHFS-
FfG Section74thmfivc
yappli fora it subjects the applicantto a civil penally of FIXO'USES
t mom undred las( NEW RESIDENTIALELECf0. S FT.
n❑ Laepeope o e yeeswith a...lecamperxsadon, — Q' STORIES TYPE CONSTRUCTION
y will do ththe, c e ri ten orpR'ere fir le(Sec.70114,Business
and Pmfc Lew J t apply m m owner of
propertyri v arL r o due.mchworklume,lfnrthroughbisOCC.GROUP RES.UNITg
ampvided to HS emrnuarenot intended.,.fisted fasde.IChvoevegg orimIn ent is sold within one yearofcumplerion,thcowner- TOTALhuilderwburdim. proving that he didwt build.,improve forpuryoseof
side).
c❑ I,mowneroRhe pmpeny.amadusively contruting witlicensed conuacmnto QTY. PLUMBING PERMPT FEE Fl.00D ZQNE APN
Lconsumer the project(Sec.70aq Business and Professions Code:)The Contractor's
icense Lawdoesnot apply man ownerofpmpeny whobuildsmimpmvesteraa,mrd PERMIT ISSUANCE
whnoonraas forsuch projects wit a cnorucmr(s)licensed pursuant to the Contractors pL9ER-DRAIN&VEN'T-WATER EA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT.DEVICE OUISIDEFIEFS
SANITARY Y N
Owner .. Data pRA1N5-FLOORROOPAREA. RECEIPT Is
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that l have a certificate mconsentto self-meum,or a certificate of FIXTURES-PERTRAP RECEIPTp
Workers.'Comprnsetion iruumseor enified c.,dr mf(Sa.3800,Lab .)which PARK FEE Y N
2Vcovers all p unla a GAS-CA.SYSTEM-1 INC.4 OUTLETS RF.CEIPI'p
I119 '— BUILDING DIVISION FOES
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE
❑ C<ni red copy rs m y f
❑ Certified copy i,file rte city inspection Division. GREASF✓INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
This sectimined not be completed ifthe permit is fortune hundred dollars(5100) SF.WER-SANITARY-STORM EA.200PE ENERGY FEE
ar less.)
I certify tat in the pormermnce of the work for which this permit is issued,lsball Ir WATER HEATER .NT/ELECfR
not employ any person in any manner se,as to become subject to the Workers' PAID
Compenamimul-awsof Califrmia. Date /TREATING Date Receipt at
Z Applicam
z 0 NOTICE TO APPLICANT:If,after making this Cenlficam of Exemption,you should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
TA hectax,mbject m the W.roce.Compensation provisimuodte labor Cade,youmust
7 forthwith comply with such previsions or this permit shall be deemed revoked, BUILDING ME
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz I herebyaffmm tat there iso constrvc6on lending.gerey fur the peff.ce of
O me work for which this permit is issued(Scc.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
U lenders Address - TY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify tat 1 have read this application and roe that the above information is MECHANICAL FEE
;'s 1 correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCC
Eh building construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
U Z .hove-mentioned property for inspection purposes. ALTERORADDTOMECH,
(We)agree ra save,indemnify end kap hamleas the City of Cupertino against
liabilities.judgmenu,costs and expenses which may in any way recrue.gainm said City AIR HANDLING UNIT(TO 10,000 CFM)
inconsequence t ranting oft pemrit.
AIR HANDLING UNIT(OVER IB,OW CFM)
Appli IlComment, f Data EXHAUST HOOD(W/DUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt Is
Will the applicant or future building occupant sme,at handle hazardous materiel BEATING UNIT(OVER 100,(100 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12.and the health and Safety
Code,Section 25532(a)P VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
,00.113711) ISSUidJ(F. TH
Will the applicant.rfumm buildingoccupant useequipmenmrJeviaBORER-COMPOHPOR 10(1
s which emit
hazardous air commitments a defined by the Bay Aron Air Quality Management BOILER-COW(OVER 100.010 BTU)
DistrietP ❑ ❑ FEB 16 1995
Yea No NEW RESIDENTIAL MECH.—SQ.SQ.Ff.
1 have reed the hazardous materials requiremcnu under Chapter 6.95 of the
California Health&Safety Cade,Sections nand 2534. I uderstand that CITY ur
Ip V C CF{
the buildingour currently haves broad,
that
it is myresponsibility tonoddy
the
cupanr of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Due TOTAL: ISSUED BY: \ J
OFFICE