27902 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOI IDI 'AL PIiRhlll NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27902
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BUILDING ADDRESS � �51`�C � x ONffN LOTH SANITARY NO MiPLI�tUNSUBMITI'ALDATE
l O a l S 5 -1(n t{y, (� l 7-4�
NS N ION& G CO JV�A M` W LIC NO:
a L CVN - 100N/C CONIKOLN
ITECT/ENGIN ER' � ��I N ADDRESS:
i WiA Lo• p- II. I � c7
Ohrr 11 PHONE:
¢ 7� tia�,'> w--A' a^ t• '<y,F>rrt"'' .-.}.' Y ^r; BUILDING PERMIT INFO- "
V (Q/ J�O _�j�iV(� Q7'Y.4„"'� {ky�P1:ECIRIC PERMTP. , SLI ' "FFEY .
A✓� ir•P"- ,... Y.ck+tis+n <ew+-:�+9+f.`-,. A.•rf". _ Je BLD71 ELECT PLUMB MECII
PERMIT ISSUANCE Qy—�jl� IQ� A
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DES RI ON
]mZ I hereby affirm that l sm licensed undermovisionsof Chapmr9(cammencingwith G�04 t-fu/��_
-00 Section 71)(0)of Division 3 of the Business and Professions Code,and my license is in pAJgELy erc(� V'
es'
full force eff If0'tJ �! a(TC'rcd`lM
<Z VUJ License Lic.N UP 70200 AMPS
y<y Dasc Conuuror 201-Islas AMPS
';)vZ RCHITELTSDECLARATION SQ.IT.FLUOR AREA 5/SQ.IT
Z_m 1 unders d mY Plans shall be used u public records. OVER 1000 AMPS
SIGNS ELECTRICAL pGJ
Y f, Licensed Professional
pa< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
0aU 1 hereby mam,that I am eaemPt from the Crnbac -law fm the
3 y following mi(gecsion 7031.5.Busimas scans Code:MY m county TEMP.METER OR POLE INST.
3 which tryuirn a prnnino conswct. ,Improve,dcmoliaM1.m rtItft en swnurt
r�Y� priorm iss issuance.vlw tequirts epplicentforsuch pemlitmfi leesig red smrnt POWER DEVICES
K p Net he is licensed punumu t e pravisi.m of Ne Cemracmis Licenx Lew pier
9m mmm1ingwia Semi 7000)o(Divuion 1af Ne Business and Rofasions odel SWIMMING POOL ELECTRIC y Q
or thathe simmimptae end Ne buffs for the alleged exemption.Myviola of /
T Section703L5h licat(ore s bauthe I noacivil el of OUTLETS-SWITCHES-FIXTURES
Z< yrny permi rvj app icon pen
W-p on mart than fiveh dolleranyeam). NEWRFSmFMIALELECTR _SQ.Pf.
K-p n❑ hesowrmrofa rafcrty,ormyemployabwiNwegesu 'rwlecompensaa STORIES TYPE CONSTRUCTION
Wim willdolhewark,and awcmuis,ntinteMWm for eSec.70 .Biima,
and Profusions C :The Cents. e.License n ly to an owner o
propenywh.milds 'masse hereon,endw d himulfor Nroughhis
ownemploym"ansi th,a at dedmaffcmdfor OCC G—R�yOUP RES.UNITS
however.Ihe buildinBm sol withinoneyearof It ion,the
builder will have Ne bur ng that he did trot build m' It purpose
We).
❑ I'somsmraf ere prolan cluivid co �ilh tensed contrumnto
PLUMBING
11' PERaMITw�� ;r?'.y. ,MNt FEE�yryr �T-f�(D,20NE APN
answa the Pmjea(See.7 usiness sons Code:)The Con _ 'Av' v
Licenselawdoesnos spplymen mrofpmpcnywhobuildsorimpm man.and y PERMITISSUANCE
who cooaacu farmnis pmjecuwi acatreaos(s)licaanipun the Contmmors ALTER-DRAIN&VENT-WATER(EA) '( '.'a,?'=�-'s'rs.
Lia se law. Y,^. FEE SUMMARY.:-y..t;i'•*'r.
❑nl am exa pt under Sec. & fm this won BACK FLOW PROTECT.DEVICE t OUTSIDE
SANITARY Y N
Owner Dane DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATLyD DECLARATION SCHOOLTAX YN—
❑ Ihertbyaffinnthnllb.sicmiGc e6fcomentmulf-insure,orec 'fins of FIXTURES-PER TRAP RECEIPT#
ZIN
�• Workeri Compensation lnsurac annfied copy thereof(Sa.3800.Lab .)which PARK FEE Y
covers all nnployec's s permit. GAS-EA.SYSTEM-1 INC.d 0 RECEIPT M
Policy# BUILDING DIVISIOTIFEES
Company GAS-EA.SYSTEM-OVER# ) PLANCHECK FEE
❑ Certified copy is hereby forno .
❑ Certified copy is filed with the ins ' o. GREASEMNUSTRL W IN'IERCEPfOR GRADING FEE
CERTIFICATE F NFROM WO RS' GREASE TRAP SOILS FEE
COMP S ON SURANCDK
(Thisxectionneadnosbecampli pcmti`sronehundraddolien(5100) SEWER.SANIT Y-STORM EA.IOOFT. ENERGY FE `
mlesIc /
Icmy any in NcpMomunceof the 'WATER a the Waloon' WATER WNEM'/ELECIR
not employ any pecan in.ay mumcr a a m become subjen Io the Workers PAID
i � Compensation Laws of Celiftvlie. Dna � WATER STEM/I'RFATING as Recaps If
APpliOns
Z NOTICE TO APPLICANT.If.after making this Catifiu¢of Exemption,you should NEW IDENTIAL PLMB. SQ.FT. TOTAL:
barons aubjat to No Worker.Compensaua provisions of the Lobar Cade,you mart
Yforthwith comply with such provisions or this lamas"I be deemed revoked. BUILDING FEE �+
1Q CONSTRUCTION LENDING AGENCY SEISMIC HE u.
z I hereby affirm diet there is a construction Iabin6 agrncY for the ,f...f of TOTAL: ELECTRIC FEE
, O the work far which Nis parent it mussel(Sea.3097,Civ.C.) _ - .. _ ,
Lender's Name n: S "•42:-:'x
r!> . PLUMBING FE
j Lcne I Address QTY; '•,.•. G' MECHANICAL PERMIT+.r... . 'V FEe fc,
I tori than 1 have read this a liwion and sum Nas Ne eMve information is s'f x�.. "hc
} 4 fY Pp MECHANIC E
comes.lags to comply with all city erW county oNinvnces and sate laws relating to PERAIR ISSUANCE
y building construction,and hereby authorise repmsenutives of this city to enter upon the CONsTRucrPNTAX
'z above-mentioned property,for inspection purposes. ALTER OR ADD TO MECII.
(We)ague m save,indemnify and keep harmless the City of Cupertino again,
lubilis s,judgmcnu,toss.adexpenus which ma,m any way.mrueagu,said C' AIR HANDLING UNIT(TO III=C96H
o qurnce ofsemraingofthis Perm it. AIR HANDLING UNIT(OVER 10 CFM)
es ignaturcofsiPplicts a neem Data EXHAUST HOOD(WA)UCD
PAID
OUS MATERIALS DISCLOSURE HEATING UNIT(TO 100. BTU) Dam Receipt0
Will she applicant or future building recursion smrc or handle hamolous material HEATING UNIT(OVE 00,000 BTU)
u defined by the Cupertino Municipal Code,China,9.12.and the Health and Safety
Cede.Sachm. 5532(e)? VENTILATION F SINGLE RESID)
❑Yas ❑No ISSUA Mfa�
Will nheappliantorfutumbuildingmcupam use is,inmensordevicer whichemh BOILER-COMP HPORiffl,"BTU) 414
p v (f'
hmardous air conaminanu u defnW by she Bay Area Air Quality Management BOILER-CO (OVER 100.00(18 U) 4141E
District /
❑Yu ❑No NEW REST L MECH. SQ.FT.
City 1995
1 have mad she hasSafety
Coe,nations rcyv,25533 under Chapter arm d the H L,UN
if the building
HORN B: o.cur Code,Sections ion,th 25537 and 25534,I undersand that �kt
it ct ons of t dos non currently have a stent,that n is mys a nee dila a notify the
,sections of the rcgwremcma which mu,be met prior to issuance of a Certificate of
Occupancy.
Owner or auNonead agent Dam TOTAL: ISSUED BY:
OFRC