27289 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO UHAIINU " I PERMrr No.
APPLICATION/PERMIT
PLUMBING-7TIDENMECHANICAL
FIC
BUILDING DIVISION BUILDING PROJF.IT IDENTIFICATION 27289
BUILDING ADDRISS: {�,.•.. ,-1 L ,'�t .'] SANIT'ARYNO. APRJCATJON SUHMMHTAL DATE
e)-3s—s5 1 AIR {OVV� y UNIT♦ LOTX /
Vf WNHRS NAME. %TONE C CTC)WSN LIC NO: 111
1 NIC CONTROL
•ARCHIIECTfF GINI E, : IJC NO: S / /_XL/us I AAt 0ock Av, ❑
CONTACT: PHONE' BUILDING ELECTPERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG RUMS MECH
PEItMR ISSUANCE ❑ Idbf 0
RES
LICENSED COMRACTORS DECLARATION APPLIANCESIDESTIAL -
OCG I hereby affirm that l snlicrnsduMnpowionos ofChW=9(Coennsii with JOB DESCRIPTION
�u00 Sectio]000)MDiviska 3 of JO Busimasad Pofmions Cade,std my lice lain PANELS
full farce nnJ of st.
QQ T ul Li Cln . Lk.M UP TO](IO AMPS
r m, Due 1 Cono+ctm }AI-IOOO AMPS
L FOyz ARCHITECTS DT:CI.ARATION OV[R 1000 AMPS SQ.FT.FLOOR ARIA VSQ.FT.
O G-0 I unukrsud my plan.shell M usd a+pubk oe v
SIGNS ELECRIICM.
Liccrucd Pmfes.itmal
Mae< OWNER-BUILDER DECLARATION SPECLSL CIR=/MISC.
5a5�0 yU I heneby eft wt 1 am exemp torn de Constructor's Lkeex Uw fm tk
u13 4 vFi following esWn.(Ssthm]031.5,Bu6rund Pmfesaiom Coo:My city o county TEMP.METER OR POLE NST.
ei O' whiOh rcy ui¢e a permit to 1—Wuct,site,iro mv,JenWl'uh,m repair cony sstuemre _
��Y2 prbr,W its is.u.me,also tryuine the appicam far loch pcnrvUo fkru signed swuneot POWER DEVICES / --��
,oe�p tMt he is licensed pursumntWthe povisimu oftd Cmv.nm's lJcmei�w if-Taper SWIMMING POOL FIECIRIC �� r
a z 9(cammcmin8 with Sstimn](IB01 of Divi.innJnfthe Bu�inos.nd Prvfeviav Code) I" `-• L"' "� VALUATION
'y N or that he is escmpt therefor,ud the bast,fordr dkgd cxerttpOart Any videtion M r
tKQ
❑Smim'/0313 by runapplia
y ntfo s punct subjcn One&,,N ®
con to a Civil pIty of OUTLETS-SWITCHES-FIJCNRES - r
Ems,
TO nm marc then five hmdmddollm($500). �
I.wowncrofdrc yempluyttaw� wsguss penwion. NEW W.
W RESIDENTELECIR Pf�
popcny,mm 'tb thcirsokcan Y V 1 TTPE CONSIRU N
s3-
will do Otc work,rued ON,Wu .w .irnoorl aroiTud fmde(See.7(Wi,Bass. —r
std Pmf.ions Code:The CmtncWr's Liccnse Law docs not apply to run mwrcr of G
Fmfeny wMboldiorimprova Nano,eM wMdonwch wonr himclforthmugh his s --
howa ,loym,povidNOwauch impovumusve mr airy ofdooBercd took lf, OCC.GROUP RFS. NITS
however,the bucithe mimprovement issold e did meyear of canove fn,tk owner- TOTAL
builM will hnvc the burden of proving ma he did on,huild u Improve fm purpose of
uk.).
❑ I.uownuafthe pup;ny,emuclusivelycmvuringwiN littnacdsnvenmW QTYPLUMBING PERMIT FEE FLOOD ZNE pPN
eowmn the Pnjan(Sec.0014,Bastnm ad Peofwiem Cd J The Contractor'.
Li.Lew does.apply W.nowocrofpopeny who Widsar hnprove Rtvem,rud PERMIT ISSUANCE
wbccor for such pmjecU witbrt.tscorq.)liccm<d lurs+runt tone Coortesi
IJneere Iaw. ALl1R-DRAIN&VINT-WATER(TA
FEE SUMMARY
❑ 1 ern esemp under Sec. ,B&P C far the mason1
BACK FLOW PROTECT.DEVICE SANITARY Y N
Pwner Due RF EIPI'X
DRAINS-
WORKMAN COMPENSATION DECLARATION MOOR,ROOF,ARILA.GOND.
I ❑ IhmebyaRnn JwlM1nvca¢niBcue of cartirnt toxlf-insore,,ra arti(v¢of SCHOOL TAX RECEIPF♦ N
WMci C Fl%TLRFS-PFR TRAP
empauuion lnsurmne aracenifid mpY them.f(Sec.7800,Tab C.)which PARK FEE Y
iTh all employee's under this peemit. GAS-EA.SYSTEM-I INC. OUTLETS RECF;IPT X
Policy 0 0 BUILDING DIVISION FEES
Cour mny GAS-IA.SYSTEM-OVER 4(PA) PLANCHECK PEE
❑ Ccrtifcdmyyishmchyron Jed.
❑ Cmifid copy is nld with tk airy haspcarim divl.lort GRE.ASEINDUSTRLWMEINTE1RCTYIOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOUS FEE
COMPENSATION INSURANCE
(TTd.sstien nei not be cmtpletd ifthepwut is fo orc honored daunts(5100) SEWER-SANITARY.STORM EA.MFT. ENERGY FEE
or less.)
Iaenify that in the perfonmru<M the work for which this pumit is issued,IJWI WATER HEATER W/VINT/ELECfR
tor ernPby mr Iersorn in any msmtu so u to bee.Wbjcm to the Worker' PAID
O z CompensatimlawiaCidifonm Due WATER SYSlikIf BEATING Doc R.ipi#
AWlicam
z O NOTICE TO APPLICANT:If,doe,mrukiog this Cotifuteof Eaemptian,you shaud NEW RFSIDFMIAL PIMB. SQ.FT. TOTAL:
r f/j berme.ubjst to the Wortd.Cmnpenuum provisiaru M the Libor Code,you muu
a 7 furtbwkh cmtply with such pmvision.u this pooh shel l be deemd mnked. BUILDING FEE
y Q CONSTRUCDON LENDING AGENCY EE
SEISMICF
I bcrchy affithu Rm mmtctio uIs a nvlendinrc
g agey fm the perfmmsemc M .,n ELECTRIC FEE
V
U O rm the wok fm which this pcm Ws issued(Ss.309],Civ,C.) TOTAL '36 •
IL Ierdu's Name
�.F lender.Adamot QTY. MECHANICAL PERMIT FEE PLUMBING REE 6_OD
r CCWJJ I certify that 1 M,c read this epPhr un,cow.two di Now infmnevan 1.
carrecr.Iapcc mcmnply wiW Vlcity ud cwmryardinrurou ud sum Ww.rclatingW PFRMTT ISSUANCE MECHANICAL FEE
bulkint,em.rreetirm.std hereby echo Dte reproenWives ofthis city to cntm upon the
U z aMwcrrrnniewed pmprny for ituµcdm m
pur( ea. ALTER OR ADD TO MECH. CONSfRUCIION TA%
(We)-gore W uve.irdenrmify W keep lurenhs ON,Cry of CuperWW rugainn
liabnitka,jdgercnta,ansa ardexpm¢s which my in troy wyrucnue rugunat aid City AIRHANDWNG UNIT(TO 10,()00 CFM) US -QD
In mnsryu woof the grunt, u it.
/,.,.T 9!Y AIR HANDLING UNIT(OVE)t 10,000 CFM)
ndw dApprcwt/CMWor Dere EXHAUST HOOD(W/DUCT)
PAID
Ht ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Due RcaipX ,,��II
Will the applicant or Noun building cceupam core m hudle hal ch)us rouerial HEATING UNIT(OVER IOO,OW BTU TOTAL:
u defd Cupertino
mby the Municipal Cade,Ch.pu 9.12,cad the He tlt sd Sefcry
Code,Sabo,23532(.)?
❑Yes 1:1 No VFN'TILATION FAN(SINGLE RFSID)
Willthcep)gn.ioncts.building by IN, ose Ar.Air
Corday vwM1ichemit
BOILER-COMP(31IP OR 100.000 BTU) ISSUANCE DATE
DknNau 0 mntuninanE n dcfircd by tk Bruy Arca Air Quality Mvugcmcnt
Di.vuin] BOILER-COMP(OVER I()0,q)0 ETU)
❑Tu ❑No NEW RESIDENTIAL MECH. SQ.FT.
bum
I �e ad the ha arax,a enucriala m9aircoo,"ud,Cowin,645 of ftNOV 15 1994
Califonda I lealth&Safety Cale.Sartori 25303.255]3.d 23314.I undemud don,if the W,king doer ort uvmmly lure a terwt,Nat It fi my ra-apmsiEiliry to ro4fy
the
cupem of he mwhenent.which mast bumct Moro,is.of e Certifia'ele of CITY yr vest CnuV
lU
x�p my.
pwnv a.mhmuJ rugent )Me TOTAL: ISSUED BY:
OFFICE