27352 grrLIk,AN I I LI FILL[IT INF INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I vc9nuT ND.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDIN?ADDRa V� ` ""- BUILDING PROJECT IDENTIPICATION�:w:q.,j3: 27354
LII
6Q-1 SANITARY NO. APPLJCATIDN SUBMITTAL.DAT
O SN E: UNIT it LOTM
PH CO.—TR 'S M LIC NO: =�11.
CONTROLp
ARCHITECHENGINEER: LICNO: ADDRESS
I
CONTACT: PHONE:
QTY.'q ,d ELECTRIC PERMIT'`9r y a;��t(fP,l��gr,Lyi-S-"`-:.- BUILDING PERhET'INFO`.
:... hA('Sc'..ia^s..Ir...-r:'. /..i.
PERMIT ISSUANCE BL 11EC1PLUhIB M❑H
LICENSED CONTRACTOR'S DECLARATION 9���`'
ncez I thereby afRm that lam licrosed under pmvisiwof Chepmr9(mmmencingwith APPLIANCES-RESIDENTIAL
WOO Section90001 of Division3of Nn Business and Pmfeasions Code.and my license is in JOB DESCRI ON
z U full force and elect. PANELS
Z u License Class Lie M ISI 0.J
UP TO 2M AMPS
vt?y Data Crow cror
�y? ARCHITECTS DECLARATION 20L�IOfq AMPS
L_p I understand my Plw shall be used u public records. OVER I90)AMPS SQ.FT.FLUOR AREA S/SOFT.
,yF n
'y� L ensW Professtonel SIGNS ELECTRICAL
xW OWNER-BUILDER DECLARATION
3 a:fI hatch)affirm that 1 am exempt from the Contractor's License law for the SPECIAL CIRCUIT/MISC.
following reason,(Section 703 1.5.Business and Professions Code:My city or worry TEMP.METER OR POLE INST.
—yJ which requvesapmoh ro comwct..her,improve,demolish,m relent my m out,
CF primroia issuantt,elm reyvirts the epplicmtfmsuchpemtitmfileeaigrvd atatemem POWER DEVICES
. 00 Nat he is littnsed pursuant ro the provisions of Ne Conoeswrs Licrnu Law(Chapter
Xo�' 9t}ommencing with Section T000)of Divisim]of Ne Business
.y asor d P ( m Coae) SWIMMING POOL ELECTRIC
the NlegW eaemptim.Any violadonof VALUATION
^O Sectim TOJl.S by any applicant fora pemit aubjaca the epplicantroecivil penalty of OUTLET'S-SWITCHES.FIXTUM r/
t mom Nan five hundred dollns(ss00).
aa-m ❑ I.asownerofNeproperry,ormyemployecswithwegesu'heirsolecomprnsvdon, NEWRFSIDENGALELECIR SQ.Fr. STORIES
_3— will do Nework,andthemmwrtisno'inundW mo(fcrtd forule(Sec.90M,
Business STORIES ONSTRUCTION
end Profusions Code:The Contmnora License law oma not apply ro an owner of
property whobuildsorimprovm the o such week himulforthrough his
awnemploytts.providcd Nati notimrnddora(fertd fm sale.If, OC .GROUP
homeverillhav ldinga ' Prov t Ni within meYeuofcomplmim,Na..". RES.UNITS
builder will have Ne bas }he did not build m improve fm puryou of
❑ I,asowmerofN ,emeaclusivel ronoacting withlicenudcmtractwsro TY• ..5�'. d4"..a. ^ COD ZONE
ewwm she Y Q J, ?+-�'se,PLUMBIwNG PERMIT: � � e g^-fin APN
pmjrn( _ Business and Profmsims Co,,)The C.mracrori -
Licenulawdaanmepplyan erafpropedy whobuildsmimproves Neum.and PERMIT ISSUANCE
whocmwcufmsuch proju acomracror(s)Iicantal pursuant Inoue CmOactols
License Law. ALTER-DRAIN&VENT-WATER(EA) }:r..
❑ 1 em exempt under Sac. ,B&P C for Nis reason 'rk'v FEE SUMMARY:,
BACK PLO ROTECT.DEVICE
Owner Date SANITARY y_N__
=;;.. WORKMAN COMPENSATION DECLARATION D S-FLOOR, OOF,AREA,COND. RECEIPfa
❑ Thereby afFum shnlheveacmtifinm ofconum Gulf-imurt,macmdfene of SCHOOL TAX Y__N�
Wmken'Comperuetim lrauranm meccnifedcnpy thereof(Sec.3900,Lab CJ which FIXTURES-PER RECEIPT
.rovers ell employee's under Nis pmair, PARK FEE Y__N_.
Policy0 GAS-EA,SYS7EM-1IN . OUTLETS RECTEIPIN
Ceram, BUILDING DIVISION FEES
❑ Cro role.pymhertbyfomished. GAS SYSTEM.OVER 4 PLANCHECK FEE
❑ Certified copy is Rled with the city impaction division. — G EANDU WASTE INTE PTOR
GRADING FEE
CERTIFICATEOMPE SATION EXEMPTION MOM WO S• E
COMPENSATION INSURAN SOBS FEE
ffhis section neW nol be compinedifNe permit is oro nehundreddollm(SI00 SE NITARY-S EA,or leas.) - ENERGY FEE
lomifythmin Ne paformance of Ne work fm which Peened'I'issue, m HEATER W/V /ELECIR
not employ any person in any mama,an as oo become sir 'et ro the
z Compensation Lewso(Califomia. Date WATER SYSIE TING PAID
Applicam Dau Receiga
NOTICE TO APPLICANT:If-afar meldng Nis CmiRuuof Eaempdon. should NEW RESIDE PLMB. SQ.Ff.
V) becomesado
subject to the Workers Compeon Pmvisimaaf'he Labor Cade, must TOTAL:
fmb-bb romply withsuch provou"M m this permit shall 4 doomed revoked BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1hereby efFmn that there is a cnomenuen lendingagency(m Ne pmromunttof
C) the work for which this posers.ie issued(Sec.3091,Cin C.) ELECTRIC FEE
Lender's Name
Lender's Address "'>r sten ?a:�'.^v::. :.�, r..:•.nx ..
V I amify Nat 1 have tend his apphennm and suss Nat Ne above infomuim is QTY.
M 'a"4,/sr?f MECHANICAL;PER hOTr.^'I'+S.'y 3. t. FE
oL;te; E (., PLUMBING E
1 correct.l agrtt m comply with ell city and only mdinancas and state laws relying. PERMIT ISSUANCE MECHANICAL FEE
v) building construction,and hereby aothorirerepreuntnives of this city to corpo
enter un Ne
Z abuvnmentionedpropmry fm impecdon pumas.' ALTE0.0R ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnifym
and keep he )ess the City of Cupertino Against
liabilities,judgmcnis.costa andaxpensm�'hmeyinany weyacmueagainsutia Ciry AIR HANDLING UNIT(TO 10.000 CFM)
in can umce of Negrmting of this t.
yf AIR HANDLING UNIT(OVER I(L"CFM)
gnomes.!Applicant/Cammcmr au EXHAUST HOOD(W/DUCT)
PAID
HATARDOUSMi,gm pI t,lSCLOSURE HEATING UNIT(TO ItX1,0ppBN) Date Raeipta
Will Ne applicant or forum building occupant erose or and t e hHemdous d Safer l
as defined by the Cupertino Mu,dcipel Code,Chapter 9.12,and the Health end SePory HEATING UNIT(OVER 100.000 BN) TOTAL:
Code,Section 23512fa1T
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) /'
Will the applican,or future buildingmcupant uses ui BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
q pmem ordevic Mant onto
a he'hict?s tar ca,aminants as defined by the Bay Arta Air Qudiry Mwgemrnt /3 A
ktdn? BORER COMP(OVER ItN1.000BN)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. V
I have rand the hasomb us muerials requimemo,under Chapter 6.95 of the 199
Califumia Health&Safety Code.Sections 23305,25333 and MM. Iun �
dersnd that /s t 5
if the building does not currently have a umnt.that it is my ospwibiliry to notify the
acupant of the mquircmcna which must be met Prim to iasuantt of a Cenife.ho of
Ocmpancy. tM/
Owner or ambonsed age, Dna
ISSUED BY: '
OFFICE