26409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHD,Du,frEiJ!CTR ,ICn PFRMIT No. O
APPLICATION/PERMIT PLUMBING-MECHANICAL b
BUILDING DIVISION BUILDING PROJECT'IUENI'IFICATHIS
BUILDING ADDRESS: /^� SANITARY NO. APPLICATION SUBMITTAL DATE.
//'V L /d e i s4;r` #P`• UNIT« IAT« _5-"A5"gy
OWNERS NAME;: PHONE CONTRACT NAME: LIC NO:
ts7- .S`> Q tti s sp- r 3S Nc CONTROL«
ARCHIIIiCT/FNGINT;ER: LIC NO: ADDRESS:
LO+4 l-r. Oh n s
CONTACT': PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MICH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB UIiSCRIPI'ION
pzZ I hereby action that L nm licensed under pmvlsiomof Chaner9(cnmmencing with
+100F Section 7000)of Division 3 of the Business and Professions Cade,and my license is in PANELS
CUUfull force and effefa� Q 3 '90 3 J UP T0200 AMPS
mZ, License Class_.S GL LLie.«
<d hate�p[r[Comruc irk
ON "' `� C 2UI-1000 AMPS
ZOr z AH ffITECTS DEC441i150 Nor— OVER I"AMPS
SQ.FT.FLOOR AREA 5/Sp.FT.
OZ—❑ I understand my plans shall be used as public records.
rn F SIGNS FF ECIRICAL
Licensed Professional
Y tt< OWNER-BUILDER DECLARATION SPECIAL CIRCUPOMISC.
K
KOri F 1 hereby Mas affirm tom I am emmpt Bmn the Contractor's Co i,:Any
Law for the
Fm-a0< following rtuon.(Sectirn 7031.5.Rosiness and Professions Cade:Any city or county TEMP.METER OR POLE INST.
which require,a I+c.it m e mea,ager,improve,damoliah,or repair any sWcture
E TF prior to its issuance,also Nref
ao returns e still icant for such permit ile nignM statement POWER DEVICES
a <<0 that he is licensed mrstammthe provisions ofthc Contractor's Liecom,Law(Cbapmr
seaW 9(commencing with Section 7")of Division 3 ofthe Business and Pmleasiom Cade) SWIMMING POOL ELECTRIC VALUATION
mv.n earths he kesempnhcrefmmand thebuis fm NealleMadeManwiw.Any violstionof
FZQ Section 7031.5 by myapphown,fora pennitxubjew therpplica,u)u civil Penalty of OUTLETS-SWITCHES-FIXTURES /' ` SQ
LSp
not more than Ove hundred dollars($SW). NEW RESIDENTIALELECTR SQ.Ff. T
KFS ❑ LasownerofthcMopeny,mmyemploywwiNwagesuN ir,olemmpcnvtion, STORIES TYPECONSTRUCIION
p�,3= willdrrhewons Cush,: sic CoxlactorintendWoro(wrcoes not apply 70 W,Boniness 1nI r^I �.
anda ery, nm Ctde:Tic Contractor's License Low docs not apply m an owner t, �. II 'I nt . Oi«'.�rx
pmpery,whnbuildnnrimprovcvhcrton,endwhothcs such wmkhimxlforthmughhf, + t ` • �•'
cmploycea.pmvidcd Na auchimpmvemems urtnotimcndedmoffc,rd for uls.
If, + :v /: t1 - n OCC.GNOUP RI3.0 r5
howwer,the building or improvement iuold widn"are yearidcamplclion,the owner-
balder will have the burden of that he did not build or ire far r L.� L v J �'OTAI:
Proving prove puryoxo
u1cJ. QTY. PLUMBING.f'ERMIT FLOOD ZONE APN
cons❑ Iuct the pr jest(S o 7(W,m Business
and Professions
thlicenxi Contractors
L7/U G
iceme ov project(Sec. ncanc Bmimeas and,whi, ions ins, ve Conon,and CJI
License Lawdocsuc apljects oh aconcpmpany whosed ua,impto the thneomeoA PERMIT"'t;
SS NCE—
Lic'ate weB for m<M1 luojecbwithacontnnm(s)licensed pursmnuo the Conhaemra ALTER T,icen.c haw. FEE SUMMARY
❑ I am eumpt under Sec. ,H&PC for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE. SANITARY Y N
Owner Uste RECEIPI'p
WORKMAN COMPI7NSAT10N DECLARATION DRAINS-FLUOR,ROOF,AREA,COND. SCHOOLTAX Y N
❑ Thereby affirm the lhavm ttnifica¢o(conxm mxlGinsurt,ora ceniGcale or RECEIPT«
Workers'Com tion lnxuranceoru nified FIX'NRESPER TRAP pcnu spy therou l5ec.3800,tai C.)which PARK PER Y N
,sell cmployec50nJepagfar®oi 6 RECEIP #
LL 77 GAS-EA. INC.40UTLETS
Policy« BUILDING DIVISION FEES
Company *�reby fumiahed.I, /7.f7/n o,, s
❑ Certified copy GAS-EA.SYSTEM-OVER 4(FA) PLANCI TECK REE
❑ CcrilicJ copy ie Ii1N with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEET
COMPENSATION INSURANCE
(This section neW not lc completed The permit is for one hundred lollars($IN) SEWER-SANITARY-STORM EA.2WIn'. ENERGY ME
or less.)
I certify that intheprsfnrmare,efthe workfor which thislcMni,is issued,l shall WATER 13I7ATER W/VENT/ELIiCfR
not employ any Person in any manner so as to becoEllt bet' th=Wu PAID
Z Compensation"waof California. !late J-'-� ! WATER STSTEAI/1'RFATING
Dae Receipt«
z 0 NOIICET .ICANT:If,a�mak thts Cent eFEx<lRatc mption,you should NEW RESIDEWAL PLMB. SQ,FT. TOTAL:
I--' ^ becmncset per to the Woducescompenu0an pmviaiom ofthe Labor Cade,you must
forthwith comply with such Provisions or his permit had be,d¢metl revoked. BUILDING FEE 6 (ICJ
CONSTRUCTION LENDING AGENCY SEISMIC FEE SO
z I thereby affirm Nm there ins constax,mnlending agrney for ths lcrformews of TOTAL: ELECTRIC FEE
U O the work for which min pared is issued(Sec.3097.Civ.C.)
Lender's Name
0 F lander,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEEL) I cenify that I have read this application and statethe the above information to
correct.Ligon,to comply with allcity unit county ordinances and state laws relating to P17RMI'r ISSUANCE MECI IA NICAL PEE
ro
F-' building man imt.and hereby nu famine¢pmsentroves f,his cityto sale,u,adoe CONSTRUCTION TAX
(� Z above-mentioned progeny for impaction purposes. ALTER OR ADD TO MECH.
(We)agrta m neve,indemnify unit keep harmless the City of Culmina against
liabiliics,judgmenix.elto it expenseswhichmbanywuyacmueugaion alit City AIR HANDLING ON]](TO I(f0D0CFM)
consequence of the grunting of this permit.
m r AIR HANDLING UNIT(OVER 10,"CFM)
SZL7-9 EXHAUST HOOD Signuwr ppbcunl/Luntnnnr Date PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,01M)BTU) Dale Rcccipt«
Will the applicant or future building occupant xtnre or handle luarvious material
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:p
Cade S[[li 25532(
Elup Yu ❑No VENTILATION FAN(SINGLE.RESIU)
❑
N'us air contaminants
a marts as building occupanttax equipment Quality Management
BOILER-COMP DEEP OR 100,000 BTU) ISSUANCE DATE
hazardous air comuminunb a defined by the Bay Area Air Quality Manugemem BOILI3R-COMP(OVER Bal BTU)
DixVict7
❑Yca ❑No NEW RESIDENTIAL MECIL SQ.Fr.
I have mad the naxardous materia,requirenlemts undo Chapter 6.95 of the OIAY 2 3 199'}
California Health R Safety Code,Sections 25505.25533 it 25534. 1 undtan
end that
ifthe building docs not curmoil have aucnant.the it is responsibility to notify the
occupant of the requirements which mast be mat tin tasmmtt of a Certificate of CI I Y
Occupancy. r- Or k.�r[n t tray
Own, ,nod agent Dete TOTAL: ISSUGD IIY: - �� /n.A/Ta.PI•�ra
OFFICE