27750 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILD n i-E E RICA[ PF,RMITNO.
APPLICATION/PERMIT PLUMBINI:-MECHANICAI.
BUILDING DIVISION BUILDING PROJECT IDEN'1'Ih'ICATION 27750.
BUILDINGADDRESS: SANITARY NO. All"PLICA'IIONN SSUB�MIII'I,ITM,DAIIi
2��y11//11!A ` W./ ry/�/ \�1�M1NI I LOT#
OW. S�NN& a vn Nt) C[0I{'S NAME
{VL E: �/ \`l1rQ Q N/C CONTROL#
ARCHITECT/INGINEER: LIC/:-5/7
/ RE D L L� ❑
O Cf: PHONE BUILDING PERMIT INFO
. f ' 1 /- `,47t� CY`� ELECTRIC PERMIT ITE
-#"I �J{'r C I [+� // BLDG ELI?Cf PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN'DAL
JOB DESCRIPTION
pym
y I hereby affit that l sumlicensed underpmvisionsof Chapfer9(r. m
mencingwith
�00 Section 7")of Division J ofthe Business and Professions Code,and my license is in PANELS
C t+II full fares andeffcet. /�
UV 6L UPT0200 AMPS
6Ppl Liccnm Class Lic.#
y6a to�/Comractor 2111-IINX)AMPS SQ.FT.HOUR AREA $/SQ.PI'.
7 Fy/ A C I'1'IiC'I'S DECLARATION COa�3 OVER 1001 AMPS
OZ—� Iundentnndmyplam,li llbeinexi spidienaords.
P: h¢w SIGNS ELECTRICAL.
Licensed Professional
K
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
i<O aU 1 hereby affirm that I um exempt from iM1 Professionsnd CanCs License Law India
follow W3ay whichinquiresa xiouSectt(a 0031.5,Hactress imprve,demolish,
Jrepai Any city orcountyTEMP.METER OR I'OhIi INS'('.
which requires n permit m amnWCL eller,improve,demolish,.r repair any nruaurc
WAY$ prion.its issuance.also repairs,the applicant foroahpe.iuo file.signed sta¢mmt POWER DEVICES
"a o that he is licensed pursuant the provisions of the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
as 9(commencing with Section J000)of Division 3ofthe Businesaand Profusions Cade) VALUATION
o, or that he is exempt and the basis for the alleged An violated of
❑H P he pion.Any fpLETS-SWITCHES-FIXTURES
act am
sunYdrddmtrx($50rmitwhjensthe aPplicenna.civilpenaltyof
not marc than five hundred Jollms(5500).
E G NEW RESIDFNTIAI.ELIiCfR _SQ.FT. STORM'S TYPE CONSIRUCI'ION
CCS ❑ I,asnwnemfthepmperty,ormyemployuswiBtwagesastheirsolecom nFltion.
a3— wHIdo the wark.andthe structure is not iinendedorofferwl forsale(S .Bun
and Professions Cale:The Commctor's License Law does no ply in an owner of
props.wbobaildamimpmves thcm.n,and who or'
himself."woughhis
employ.,provided th:u such improvemcn' nmimm�dcdmoffcredforsale.IL OCC GROUP RES.UNITS
however.the builAing nrimprovemem is ithin nnc yearof cnmpleiion,the owner- L; /—
builderwillhavetheInno of pros that M1c JiJ not build ar improve for purpose of
sale')' _ QTY.NDRrS-nO0R.ROOF.
BING PERMIT FEE MOOD ZONE APN
❑ %asawneroftheprope exclusively contracting with licensed contractors to
commuet the project(Sec. 044,Business and Professions Code:)The Coatmemrs
License Lawdoesma.ppl roan rof Propenywhnbuilda orimprovesthereo ,and
who contracts for such pro cis with a c.ntractngs)IicensW pmeu:muo the Convu VI?N'1'-WATER(EA) FEESUMMARY
License Law.
❑ I am exempt under. .E &P C r .DEV ICE OUTSIDE PH-
SANITARY YN
Owner Date RECEIPT#
ROOF. REA.COND.
WORK AN COMPENSATI NDBCL SCHOOLTAX YN
❑ Ihcmby nflirm 0m huvcacenihcmc.fc us
to If-i s ,nr4ccnificvm ofAP RECF.IPI'#
Wmkcrs'ComPcnsalion surance.ra ceni(¢t mW
f(Sec.JN(IIL Lab CJ whit PARK THE RF.CEIPI'p N
cover..all employee's un err this permit. �: AS-G.SYS - NC.4 OUTLETS
Policy x BUILDING DIVISION FEES
Company GAS- YSTEMOVER 4(EA) PLANCHECK FEF,
❑ Cenifedcopynh by famished. - \ /
❑ Certified enpY is fil d with the city i,"ation division. 1 GR' SFANDUSTRI WASTE INTERCEI'IOR GRADING FEE
CERTIFI TEOFEXEMPTIONFROMWORKF,RS' REASETRAP SOILS ITE
'OMPENSATION INSURANCE
(Thissectionnesdno becompleted if Ne permit is fur one hundrWdollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
Icenify,hininfleperf n cof the work far which this permit kitoced,lsh WATER HEATER W/VENT/ELECTR
noI employ troAn
y son in • ... m as hecamc subject to the W, civ' PAID
Compemationlawsuf Califom . Date WATER SYSTEM/TR]ATING Date R p
Applicant
zC NOTICE TO APPLICANT:lL, fmr eking thiaCmlficme of Excmpti .You should NEW RESIDENTIAL PLMIL SQ.FT. 'OT
"C became subject to the W.rkerS Comps tion Pmviziona.f the la ode.you mu,t
a7 forthwith comply with such provisions or 's Permit shall be de ed revoked. BUILDING HE
0. Q CONSTRUCTION LE ND] CY SF,ISMICFEE
J
I hereby affirm that is a construction lending agency for the performance of Z TOTAL: ELECTRIC
U O the work for which this permit is issued(See309].Civ.C.)
FV) qZ
Lender's Name LUMBING
u-' F Lander,Address QTY. MECHANICAL PERMIT PEE
U 1 cantly that have mud this application and store that the shave informminn is PMIiCI IANICAFELE
FEE
>" W correct.lugrccmttsmply with sell city and county ordinances anJ simelawsrelatingw PERMI'TISSUANCE
f^ y buildings.nstruction,mdherebyamhmiurepm,enmtivesofihlscitymmmruV nthe CONS]RUCTION'AX
V Z above-memianed property for inspection puryous. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep harmless the City of Cupertino agaiui
liubilities.j mems,cosis undenpenus which may in any way accrue against said City AIR HANDLING UNIT(TO 10000 CFM)
nscq m.nf the Braining of this permit. 1
ANULING UNIT(OVER 10,01%1 CIrM)
Sign aAPplican/Contractor Date ]IAUST HOOD(W/DUC , PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 101.000 BTU) Dore Rx t
p
7ill the applicants future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Ctdc,Ch,he,9,12,andthe 11.11h and Safety HEATING UNIT(OVEN 100,IXX1 BTU) IAL.
Cada Section 25532(apl VENTILATION PAN(SINGLE RESID)
❑Yea ❑No
ISSUANCE DAIPIS
R''�
Wilhhe upplicantor fuwm Building«cupaniuseequipmemmdevicexwhich emit BOILER-COMP Off OR IM."BTU) r• p O haeardous air cormaninams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BI IW
District?
11ElENT
Ycs No NEW RESIDIAL MECII. SQ.FT. DEC 12 1994
I have mad the havadons materials requirements under Chapter 6.95 of the
Cnlifomia Health&Safety Code,Sections 25505.25537 and 255]4. 1 understand that
if the building does not currently have a tenant,that it is my}esponsibility to notify the CITY set LurtM
accupem of the requirements which must he met prior to issuance of a Cenificam of
Occupancy.
Owner or awb.rizN.gem
Data TOTAL: ISSUGD RY
OFFICE