27203 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -W"r-�rml PERMITNO,
APPLICATION/PERMIT PING PROIMTIDMEC�NANICAL
JBICA 27203
BUILDING DIVISION BUILDING PRUJF.CT IUENTIF1CATlON
/BUILDING ADDRESS: SANITARY NO. APPLICATN)NSUBMrITALDATF:
r62 45 UNIT N LOT I
OWNERS NAME: PHONE: CO ACTOR'S NAME: LIC NO: I`N�p/ CONTROhN
CHITYCDENGINEP : LIC NO: ADDRESS:
ire w . 5-
BUILDING PERMIT INFO
CONTACT: L'-y DN�-_j QTY. F1,ECIRic PERMIT FEE
/J }l 1 PERMIT ISSUANCE BLDG E E PLUMB ML El l
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDUsT1AL LOB DESCRIPTION
Ry.Z Ihemby affirmthat lam li¢nmd tower Po.iuomof Chepc9(cormrmclegviN
omW Section''/0110)of Division 3 of the Busircav eel Nofesiwu Code,and my licuue is N PANELS
facer carWeRecr.
<Z� litems Clsa Lica UPTO200AMPS ��,
?y Date Cmtrxt« 201"1000 AMPS
20sirz ARCHITECTS DECLARATION OVER 1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O7_� IuMawtl my plw shall be u•M republic rtcoNa.
1:-rn SIGNS ELECTRICAL
Liccn.vd PwfaionW
�s < OWNER-BUILDER DECLARATION SPECIAL CIRCUITRASC. [
XdXOaU 1 hereby•li m tlw I mo camp firmWe Cmtnews'i L w Law for that
J,0 t¢; folbwini rtu«t.(S«uon'/0315,Bushes urd Pmfesai«u Code:Any ciry or munry TEMP.MEIP.R OR POLE ITST,
Stil which mlube•permit to rnnstnrn,Jter,iorpro.e.dctmlish.«tcp•ir my.^rtme POWER DEVICES I 1
ttenY� Pim to ira isuaoA,'HIw)rcyoire thO towliam for such permsI to file a signal nate est re q n If�l
O Ost he is li¢nxd punuent to Ilse Poviuma of the Conuamola License law(CTaper I'�., I'_✓
���� 9lc«mrerwiog with Sctim T0007of Divlilm3oftK Bu.iocs and Rofaima code) SWIMMING POOL BLECI1tIC VALUATION
w_H nNu he iacsmtpt thcrtfrom artl the b•dsf«de allcgd cacmµian.Any viduiao of 1 I^
CZQ Smion'/OJ15 by any applkanl fmapamit wb3nuthc gglicwtwacivil perWtyof OITIIJUS-SNITCHES S L V t
PFG not more than five numbed thAlus(SSIMq. ree, ri 1
C3F ❑ I,vowreroflle PaRnY�mmyemPloycswilh wngomllmireoleampvmdm, NEWRESIDEM'IALFJ.ECIR SQ.FT rqd STORIES TYPF,CONSTRU ON
y $ will dothewons,Cor : she Commit
o mi fiat act,la Use
apply
1044,Blninea Nk
poverty
.1olnu Calc:The Cmuacwla Scene lav docs not apply w an awrer of
P QTertY wbabuilda«irrrpwvnthermn,and whod«a ouch wvvkhirtnelfm Wooghhf, `d
pour mPavemm OCC. ROUP E�N
ownempl theca. for that urchi uarenntimadednofferN fn We.IL
however,Ile btiave the
hu impovcmcm is sold within orc ycv ofcompvcfoO the OsO 4 �^f
builder will Mve the nurdrn of pwving that he ditl rrd WilJnimpovc f«purpec a( TOTAL: �.OV
m eJ.
❑ I.nuwrerof de poputy,we•clusivclYarmxtinlowiNlirmanicmtranonw Qom' PLUMBING PERMIT FEE FLoO Z
curuo-um Ilse"*I(Sec.7W.Bain old ProflOsluu Code:)The Cmtreaar'a
license Lawdaci not•pplY to mlowrerofPaprny who bulMH«impmvethcrtm,mld PERMIT ISSUANCE
who cntmcis for such Pmjas wish acumxtor(s)llcomed pmauanuo the Crmmwe is
u
Ticas law. ALTER"DRAIN&V INT-WATER(IA) FEE SUMMARY
❑ 1 am cscmpt wdn Sa. B&P C f«thu roman BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owra RECEIPT'♦
� WORKMAN COMPEIJSATTON DECLARATION DRAINS-FLOOR.ROOF,AREA.COND. SCHOOL TAX Y N
I hereby affirm that 1 have a certificate of conical to¢If-imum,«•¢nBletc of RECEIPT
'mkai Cmvlematim lnwmrreenacenifida9Ythcnof(Sx 3800,Lab C.)which PARK TRAP PARK FEE Y N
.mm aR enn'byv s male Oda P rmit' GAS-EA.STS 7ENI-I INC. OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
C—Puny GAS-EA SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Ccnificdc,yisleoebyfrrdahM.
❑ CenifiMro iaRkdwi$O cityirups M&Yiaim. GREASPANDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This smion mass]not the completed iffloc permit is f««e hmldred dalWa(SI00) SEWER-SANITARY-STORM EA.36OFT. ENERGY FEE
«la.l
Iccnify tMt N the Prf«mmce of the work for which Ws permit is is ISI WATER HEATER W/VE'T/ELECTR
not employ..myylooses r in my w s b 0_�eet Rita. PAW
fCpop z A TIf AF J� owls Z WATER STSIFAI/HIEATING Datc RcaiPN
z p NOTICI! PLICANT:If,after maks 8 CW f cmTKim,You should NLIV RPSIDENTAL PIJdB. SQ.PT.
I-. (;0becurrc subject to Oe WMda C«nprnsetim Tomim aiaofthe labor Code,you must TOTAL:
forthwith comply with such Pav'.i.w.or NH permit shell ha deemed m,akee. BUILDING FRE
1 (] CONSTRUCTION LENDING AGENCY SEISMIC ITS
Z I hceby off Nu Ihete u•ccmbvclim Ivdirq agvwy for Ile perfanmrec of
V pthe wor4 f«subsea tni•pamit is sawed(sec.3091,Civ.CJ TOTAL: ELECTRIC FIT, Z, Oa
Leade"Name PLUMBING FEE
C U Lrnder'a Adrbus QTY. MECHANICAL PERMIT FEE
V I acnify,that 1 have rod dust applicatim and n•,"that this,above le fmmaum is
1"
correct. l alone to comply with Hl city"munry mdirwt¢s urduau laws mlating w PERMIT ISSUANCE MECHANICAL.FEE
building canurtsction,aM nereby audwrixc rtprernwtiveofihla cityuenlcr upmim the, CONSTRUCTION TAX
U Z above-oelitimnl Popcny for inspcctimrT
Noas. ALTER OR ADD TO MECII.
(We)agree to wve,iMrnmify ami keep humlen the City of Cupertino agamo
Iiabilitie,jWprcnu,toss oral espcane which mayin any way=ma atinu nsaidCry AIR HANDLING UNIT ITO 10."CFM)
of the granting of this pvmit.
APR HANDLING UNIT(OVER 10,0)(t1 CFI,)
Signammof Appliwm/Comrtctar Dme EXHAUST HOOD(WMUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE TREATING UNIT TO IW,000 BTU) lMn —W.—"—#
Will Ore applicant or future hoiddlnS cecuTsm tome or hardk hamdwu nomas,) -/
s defircd by the Cupen ins MmEcip•I Cadc,Chapter 9.12.arld this,Health and Safety HEATING UNIT(OVIIR 100.000 BTU) TOTAL: / �•OO
Calc.Scnion❑Yn32(v)t ❑No VENTILATION FAN(SINGLE RESIN)
eBORER"COMP(3HPOR IM.000BTU) �nSIS
Will pskcfd NDATE
Ntthcepplicunnfumn buildioSacegntureeRuipmcm mdeWm which mit Y S {J
,allogik
zmdous air canwnivnt•as defirrd by the Bay Ama Air Quality Muugeroent BOILER-COMP(OVER 100,(Xp BTM rn[k
Netv ❑Yes ❑Nn NEW RFSIDEJTIAL MECII. SQ.FT. OCT 0 ^Y
190JAT
1 have rem the Sectiones 9)5, mm3 undo Cluper ern d Nc
ifthestia))calm&lot etycur Cole.Sections a e25505,t it is my
1awenrand that \ilI"jr
ifroloom Of don not Which
Mu aanttltatuia m kak+�Ct41�1
g r rreaPnduliry to miry tn< IVU
acapont of the reyuiraenu which muet b<nref pdur to isuuree of a Crnificue of
ocapuney.
c
Omvmautlnerissdagem Date TOTAL ISSUED BT:
QF