27322 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.11ittN'�-RicU I'21 AI. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT'IDEN'TIFTCA'I']ON 27322
BUILDING ADDRESS: T
SANITARY NO. APPLICATION SUBMITAL DATE
1/+ a Uhl LO
:KS NAME,: PHONE: CO RACTORS E: LICNO:
NIC CON'IRfll,p
RCHI'IECT/ENGINEER: LIC NO: ADORES . S• �fa.zc J:Q,f El CONTACT: PHONE: BUIL-DING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG IiLIiCT PLUMB MECII
PERMITISSUANCE, ❑ ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL '
GCi I hereby affirm lbar lam lirtaxedunde,pm,ixiwo.fCh.pmr9(tnsmmencing with JOB DESCRRII ION)
u100_ Sectio,7000)of Division 3ol'rhe Bminessand Pmfe,own,Cale,and my license is in PANELS �
K W full force and effect. V s ♦,/^VJ/
U[I
cA<m License Claes Lic.M UP TO 200 AMPS
H=y Dam Comrmmr 201-1000AMPS SQ,FT.FLOOR AREA SISQ.FT.
Z~OyF ARCHITECTS DECLARATION OVER I"AMPS w
OZu,❑ I undennd my plans shall be used as public records,
y W SIGNS ELECTRICAL.
Licensed Professional ,\
�y.recQ OWNER-BUILDER DECLARATION SPECIAL CIRCUO'/MISC.
XOau 1 hereby affirm that 1 atm exempt from the Commcmrs License Law for the - \ \
W3ay following reason.(Section 7031.5.Business and Professions Code:Any city.,County TEMP.MFTF.R OR,OLE INST.
I_-�Oj which requires a ferric m consumer,alter,improve,demolish,or repair any storepup,
$�}5m its issuance.alsorequires thea Heart for such permit file a signed statement POWER DEVICES
poorpp pcsmi gn �•
WCp chat bets licenscdpasuam to the Provisions ofthe Contractor's License Law(CWpter SWIMMING POOL ELECTRIC \
,E:0 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) \VALUATIO
W:2, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of •\`�
G
t'S� Sect ion 9031.5 by any optic icant fora pernh subjects the applicant to u civil Penalty of OUTLETS-SWITCHES-FIXTURES
< ll
d d
d
h
five h
not mom than ve unreoars(S500).
$Sp NEW RESIDENTIAL ELECfR _SQ.FT. \ ,-ST IE TYPE CONSTRUCTION
,F-� ❑ othewrk.andepropcny.ormyemployecswithwagesasthe(Ses.c0mpeminess
63— will dothework,ande:The os is not is License La do es not apply T04q Business
and Profccsinm Code:The Contrumrs License Law does not apply In an owner of
property who builds or improves thereon.and who does such work hrmselfo Brough his
OCC GROUP RES.UNITS
own employees,provided thuch improvements are not intendedoroffered burials.IL
ut.e
however,the building or impmvemint is sold within ate yearofcompletion,the owner TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT PEE FLOOUZONE APR
E] Lm nef
nwofuhepot,sco wit exclusively comraam
ing with licensed contractors
msrd J
uct the project(Sec.9044,Business and Professions Co 'Ile Contractor's
License Lcwd«snmapplym an ownerofpmpery whohuildsorimproves Jumped,and PERMITISSUANCH
whocmdracu for such projects with acomnetogs)li«ved pursuant mhe Contmaor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Low.
[Il am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICE, OUTSIDE;FEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AR G,COND. RF,CH1PTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm thalhave acenifcute of comsem molt-insttrt.on ecnificam of FIXTURES-PER TRAP RECEIPT#
Workert C.mpinsatio i lnsu,ancemic certified copy lhereaf(Spe.3800,Lnb C.)which PARK HE Y N
rs all cm In ec'e under this v RECEIPT#
p y perm GAS-FA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION FEES
Policy M
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEF,
❑ CcnifiW copy is hereby fumishcd.
❑ Certified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING -ME
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Hiksection need not be completed ifthe Permit is for one hundred dollars(5100) SEWER-SANITARY-STORM F.200FT. ENERGY FEE
or less.)
I ten ify that in the Performance of the work for which this permit is issued,l shall W THRW :NT?LECTR
nm employ any person in any manner s.as rr become subject in the Weaker,' PAID
Compensation Lawsof C.Idmio. Dam WATER SYSTEM ATING Data Rcceipta
pZ ApplicNOTIant IDENTIAL PLMB. SQ.PT. TOTAL:
z NOTICE TO APPLICANT:ILafter making this Cenifcam of Exemption,you should
(~ h becadm subject to the Worker's Compensation provisions ofthe Labor Code,you must
a , forthwith comply with such pmvnw.ns or this permit bat deemed revoked. BUILDING FEE
00.., Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
2 I hamby affn t thin them iso conxwaiou lending agency for he pMomomm.1' ELECTRIC FEE
U O the work fill which this penniu is issued(Sec.3tN],Civ.C.)
Lenders Name PLUMBING FEE
u's F Lender's Address QTY. MECHANICAL PERMIT FEE
C U 1 certify that 1 have read this application and sumo that the above information is MECHANICAL FEE
>. fJa correct.l agree acomply with all city oral county ordinances and scam laws relating on PERMIT ISSUANCE
Fbuildingeonsruction,and hereby authorize representatives ofthiscicy to cmcrup.n the CONSTRUCTIONTAX
U 7 above-memioned papery for inspection purposes. ALTER OR ADD TO MECH.
r'7 (We)ugmc to ovi ,rapport ly.,at keep harmless the City of Cupen in.against
Iiabilflat, g cros.e. sand cxpcnaps Itchy in any way accrue egainstsudd City AIR HANDLING UNIT(TO l0.0110CFM)
mco 4ucnc a ranlin fthis rail.
AIR HANDLING UNIT(OVER 10,000 CFM7
ignnruer pplicvnUC.n(racto, Date CXIIAUST ww
HOOD(W/DUCf)
PAID
IIA%ARDOUS MATERIALS DISCLOSURE HEATING UNIT TO IN."BTU) Date Receipt#
William applicant or future bcilding.ecupantstem or provide hrvmduus material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as deined by rhe Cupertino Municipal Cade.Chapter 9.12,and the Health add SafetyOF
Cale,Section 25532(^)? VENTILATION PAN(SINGLE RES ID)
❑Yes ❑No ISSUANCE DATE
BOILER-COMP(3HP OR 100.000 BTU) f11 A
Will the applicant or fuambuilding«cup,tuns equips ntordevices whol umit P 99
hmefdous air connections,az defined by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? NOV 22 1994
❑Yes 11 No NCW RESIDENTIAL.MECII. SQ.Isf.
1 have mad the hmafdoas materials oequircmcnts under Chapter 695 of he
California health&Safety Code,Sections 25505,25533 and 25534. I undersand Nat
robe building does no currently have a reward,that it is my responsibility to notify Be CITY Urloafer \'
occupant of the requ lrennects which nnust be met prior m issuance Of a Cenifcute of
occupancy. -
Owner or authosncd agent Dam TOTAL: ISSUED BY:
OFFICE