27763 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY t
CITY OF CUPERTINO •.EVECrRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 27763
BUILDING PR09dEC'1 U EelfIP1CA'1'ION
BUILDINGADDRCSS: SANITARY NO. APPLICAI'IONSUBMIITTTAALDDD'A�TE
UNIT is LOT#
OWNaERS NAME: PHONE: CONTRACT'OR'S NAME: LICNO:
1 , "M\ ® III C— N/C CONTROI,a
RCHITF.CDENGINEER: LIC NO: ADDRESS: �- ` ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
ELECI'RICPERMIT FEE BLDGpif I��B H
set, PERMIT ISSUANCE B
/
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Metz I hereby affirm that l con licensed undupmvisionsofCapter9(commrncingwiN JOB DESCRIPTION
4100 full Section and effect. Jo(Nc Business and Professimna Code.and my license is in PANELS �f
FetZI1... full force and effcm. •s�I\�\
FZW License Class Lie.# UPT02W AMPS
mQd Dau Connote Nd-IOW AMPS
F y Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Oz^M I understand my plans shell be tied m public taords. OVER IOW AMPS www�.���
�y�u! SIGNS ELECTRICAL 1
Licensed Professional - l•
etetQ OWNER-BUILDER DECLARATION' SPECIAL CIRCUFDMISC.
px'OyU I hereby affirm that 1 em wempl from the Comments License Lew for Ne
fallowing reason,(Section led L5,Business and Pmfeesions Code:Any city m county TEMP.METER OR POLE MST.
C E: which requires u permit I.construct,eller,improve,demolish,m repay any mucmre
priono its iwounce,also requires Nevpplievot for each pe eatignisi atemenr POWER DEVICES
yetjet�p that he is licensed pursuant to the provision oflhe tor' L anti Lew(Chapin SWIMMING POOL ELECTRIC a Lxo�' 9(commeming with Section 9000)afDiviem the Business ami Prefeseimu Code) 1 VALUATION
m
W_ nnhatheisexempuhemfmmandthebai rdealleged so In .Anyvioletionof OUTLETS-SWITCHES.FIXTURES / �
Section 7031.5 by my applicant for rmit subjects the spplicmi , a eivil penaltyof
not more than five hundred do ($SW).
M Lasownerof Ner NEWRESIDENTIALELECIR _SQ.FT. STORIN TYPE CONSTRUCTION
m ❑ p y, isnoti ployeesroffered gesrwile: lecompemadon,
p- will Prfiewmk cslto Careisnot inLnJWorafwdoes war (S .1044,ownerof
and Pmfesi no Cale:The Cammctor'a License Law does not app to rn owner of
pmKoywhtbuildsorimprovesthemon,endwhodcessuchwark Won Iforthmughbis OCC.GROUP RES.UNITS
employe ,provided that such improvements not deJoro eted foisale.TL
however,the Adingorimpm ementis Idwil n a mpltkm.,heownw-
huilderwillha theburdena rp
I h d Idn,i.,o forpuos.rd WN
sle.). - :wt. .
CIs I, comer fie pr elycommcring with' vectoa to TX. "PLUMBING PERMIT FEE FLOOD ZONE APN
com mit the pro r(Sea 1 em on"s and t
Pearso oda:) Contrwmr'r, - -
LicenuLawdoes ate,
tom ower ofpropatywh �ldsari v wean,and PERMIT ISSUANCE
whiametmutsfms ch prdjensw coduactor(s eruedpu sntlothe Conaector's LTER-DRAIN A,VENT.WATER(EA) FEF.SUMMARY
License Law.
❑ I em exempt der Sec. B&P C fDTIVENq
Or this meson B K FLOW PROTECT.DEVICE O .1
SANITARY YN
Owner it Dile DRA -FLOOR,ROOF,AREA,COND. RECEIPT#
W, COM TION DECTARA SCHOOLTAX Y N
❑ I hereby affirm that l l vc acmibehordconsem w sel6ins o smote of FIXTUR -PERTRAP RECF.IPfp
Worken'Comprnsmionlre unceoracertfiedwpy Hereof ,Lab C,)which PARK FEE Y
coversell empluyee'sunder ie permit. GAS-EA.S TEM-1 INC.40UTLETS IHCEIPTa
policyp BUIL DIVf51 FEES
J Company AS- S'IT.M-OVER4(EA) PLANCHECK FEE
C r Its III
E7 Ceni6edcopy is hembyf fished.
$I Cenifed copy is filed wiN ecity inspect \ REASEIINDUSTRL WASTE INTERCEPTOR GRADING FE
CERTIFICATE OF\XEMMION�EMRO OZ\' GREASETRAP SOILS FEE
COMPEN INSURANCE
(This sectionneednotbecothepermit is faranSEWER-SANITARY-STORM FA.200FT. BNFRor lest)leenifythatintheperfommworkuneducleNiWATER HEATER WNENT/ELEM
not employ my person in tiny mammy a s to become sPAID
CompensmionLesaf California. Dau WATER SYSTEM/TRLATING pa Receipt#
O z Applicant
Z— NOTICE TO APPLICANT:If,after madding this Cereificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
I' .N., become subject to the Worker's Compensation provisions of the Labor Cade,you must BUILDING 'E
> forthwith comply with such provisions or this permit shell be deemed invoked.
steel 16
CWn Q CONSTRUCTION LENDING AGENCY SEISMIC iE 2
z I hereby affirm that the. cansvuction lending agency for the perfomemce of
U the wank fm which this permit is issued(Sec.3091,Civ.C.) _ *. F.LF.CTRI TLE
Lender's New — "' - PLUMBIN
OF Lenders Address QTY:;;,.',y ��`MECHANICAL PERMIT FEE
U 1 certify that 1 have mad this medication and tram that she above information la ''4. "II q c Y pP to MECHANICAL E r
Drat Iagreemcomply with ell city ab aunty oNinences end saulawn miming to PERMIT ISSUANCE
�^ building construction,and hereby sundown repeweenativesofadmd'yto eoarupon the CONSTRUCTION X
U z alawc-mentioned property for inspection purpous. ALTER OR ADD TO MECH.
(We)agate save,indemnify and kap harmless the City of Cupertino against
lubilities,judg ems,costa vyyl expenses which may in anywayeccmcaguirn said City AIR HANDLING UNIT(TO 10,000CFM)
in nee m ofthe grin ttlg of this permit. -
�f� AIR HANDLINGUNIT(OVER10,000CM7
Si time ofA is UConuuctor 2 aD to EXHAUST HOOD(WMUC1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date caiw It
Will the applicant or future building occupier more or handle hazardous material TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health end Safety HEATING UNIT(OVER 100,000 BTU)
Code.Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑Na
ISSUANCE DA
Will themppiicamorfulare huildingoocupantauequipmentordeviccswhichemit BOILER-COME CHECK 100,000 BTU) p
hazmdom air cantmnrnus
inrs defined by the Bay Ams Air Quality Management BOILER-COMP(OVER 100,000 PAID
Ir A I D
Disrriml
❑Yei ❑No NEW RESIDENTIAL MECH.—SQ.Ff.
1 1 have read the hazallous materials requirements under Chapter 6.95 of the MAR 21995
California llsolth k Safety Calc,Sections 25585,2553]add 25534. 1 undersand Nat
if rhe building does not currently have a tenant.that it is my responsibility to notify Ne CITY ur sur . 1
escrow,of the requirements which must h met prior to issuance of o Cenificea of _
a
Occupancy. 1472
Owner cer aolhndzed agent Date ISSUED BY:
OFFIC