27984 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11 IIAINC-4.LhCTRI AI. PERMITNO.
APPLICATION/PERMIT PLUM ING RODE I[DENTICAL
FICA 27984 7 9 O A
I{UILDINIi DIVISION BUILDING PNOJKCI'IDEN'1'14'ICA'fION G OLI
BUIL DING ADDRESS: 1�II,r SANITARYNO. APPLICATION SUBMITTAL DAIL
UNIT# LOT# sam�ly
O N' 'NAME PHONE: CO ACTOR'S NAME: ` LIC NO.
(N . a GG I'�$„/L/�$ NIC CONTROL
.ARCIITECT/IiNGINEER: LIC NO: AD S:
03
CON/T/A��/T-p /� (1/.41y # a J P rNCC::/{�� /}/��,/�./ QTY. ELECTRIC PERMIT FEE )WILDING PERMIT INFO
\eo4/ c / �I # U 'DP V �// I ` B PLU MECI(
PERMIT ISSUANCE
LICENSED LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
TOB DESCRIPTION
C=ZI affirm that l um licensed under prvlsi.nsof0upecr9(commencing with
WOO ,a 701Apof Division Sof the Bminnssand Professi.ns C.&.ond an,license is in PANELS
Fyn full force snit effect. 3
U Z�J t UP TO AMPS 2�
fZm D-.-/Clazz Lie
.N 1
m 6 a. Ila¢ Comrcnra 201-IOW AMPS
F h{ ARCIIIIECTS U '1'IOi SQ.FT.FLUOR AREA arsQ.4T.
'GOm� OVER 10(10 AMPS ��""
O"/_i-O I unde plans shall be used Rolrecd 3
F,z F m SIGNS ELECTRICAL (�fa
6�$pa Li of NER-BU I. DEC ION SPECIAL CIRCUITIMISC.
CKOL V I hereby:dtirm Nal I nm cumpt from the minor's License Law for the
m3ati following revon.(Section)031.5,Business end are. ons Cade:Any city or county TEMP.METER OR POLE INST.
FLLOQ which requires a permit to construct.alter,im vet de lish,or repair any stme ure
prior to its issuance,also requires the apple forsuchpe itro0leasignedsmlement POWER DEVICES
WE Q Oz that he is licensed Pursuant to the provi.i sof the Cnmrac is License Law(Chapter
CLOLLs
9(commencing with Section 70(ap n svio.n3of the Basins and Professions Code) SWIMMING POOL ELECTRIC VALUATION
pjyo unhllcisexnnpttherefmman ebusisfntheallcgWena prior.Any violation of
FZQ Section 7031.5 by any applic for a permit subjects the appliatmacivilpenaltyid UTLIffS-'WITCHES-FIXTURES
dC�SF
I more thin five bond .(In,,($500).
C NEW RESIDENT I
TIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCT n❑ Lasoso ll ropeny,ormyempl.yees with wages asth irsolecompensunon,
y3. willdashewn dlhe nrc,urc isnot intondW ornlfercd Tarsal Sec.7044,Business
.it Pref nx Cods:The Crummuc r s License Law does note ply to an owner of
pro y whobuildsurimpmves thereon,andwhodoessuchwurkhi selforlhmughhis
11 employees,provided that such impnrvcn cntaaren.l intendedor reandforsaleAf, OCC GROUP NES.UNITS
to egthebuildillunFovcmentisml i,hi ncyearofcom etiom,he.wner-
builde will have the burden of passing that ,b Id or impr,efor purpose of
sJ1c'I' QTY. PLUMBING PERMIT' FEE
❑ I,as w ndthep ped"inne cly nhaaingwi, on,ructorsto FLOOD LONE APN
ms0ud I npmjcm(Se 7( s. Profession mm)Th cConwctors
License Law oe a ,app. o epmpen It ds or improve Hereon,and PERMIT'ISSUANCE
Mal
whoc.mrac¢ r aun.onur(s)Iic sed Pursuanuo Jme Cunlrec,ors
License Luw. s ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I em extmtp under Sc B&IP C for this reason BACK P RO'1'ECT.DEVICE OUl'SI I:FEES
SANITARY YN
Owoer Dae INS-FLOOR,ROOF,AREA,COPD. RECEIPT#
WO KMAN COMIf DECLARATION SCHOOL TAX Y
�I❑ Iherebynffrml ITh rnva are sola of nmxenl aP sell-insurt.ora cenifcute of FIXTURES-PER TRAP RT EIFF
Workers ComNnsatio n certified copy Nerw!(Sec.3800,Lnb C.)wh' PARK ME V N
Rdcovers all employees user N'man GAS-EA.SYSTEM-1 INC.4 OUTLETS R
leyls BUILDI ^.96N FEES
Company GAS-EA.SYSTEM OVE 4(EA) PLANCHECK FIi.
❑ C,miied anpy is hereby famished.
❑ Cenifnl c.py is fled with Ne city impecsion division. GREASMNDUKTRL 'INTERCEPT GRADING ME Al
CERTIFICATE OF EXEMPTION MOM WORKERS' GRFASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not la,completed iflhe permit is for one hundred dollars PS 00 SEWER- -STO M FT. ENERGY F li
.,less.)
I certify that in the Ledo atce.11he work for which this permit is issued.l sh 1 ll? TER 'L'
tot employ my person by manner so as to become subject to the Wake PAID
C.mpc mon Luw' t i' ia. Date W YSTIi REA ING Date pt#
ZZ Ap
O Til CET A ,ICA cr Ih' r' t,you sTm�old NEWR EM'IAL PLMB. SQ.FT. T L:
Fbecome sabje oche Wm r. ompe lio pro' the .l �,p,� us' BUILDI
a forthwith comply with such provisions or this permit shall be deemed revoked.
C [� CONSTRUCTION LENDING AGENCY MPAID
Z Ihereby affirm that there is a construction lending agency for the performance o! :::!07F
UOIlia work for which Nis permil is Issued(Sta.3097,Civ.C)Lender's Nomefinders Address QTY. MECHANICAL PERMIT FEE
0 U 1certifythaIhave rent This application and nem Thal she oMve inf.rmaiun is nmect.I agree um.mply with all ci,ionle or,onfinances and state laws neutral. PERMIT ISSUANCEiA building construction,and hereby andome representatives ofthiscity to enter upon the U Z aMwe-mentioned property for inspection Purposes. ALTHRORADDTOMECIL w-(We)o c wsave,indemnify and keep harmless the City ofCupcninoagain,
Imnies ' Jgmems,c. nd..,nsb,w1d may ina way accrue against said City AIR HANDLING UNIT(TO 10,O0al
Gurnee nfl ronlin8.fIbis pcAIR HANDLING UNIT(OVLR IQOIXI CPM)
S' wrc pp um c Das EXHAUST HOOD(W/DUC1T A➢ARDOUS MATERIALS DISCLOSUREHEATINGUNIT(TO100,ntXIBTU) p
Will lbeapplicanl.,future building occupant store or handle hazardous maerial HEATING UNIT(OVER 1041"BTU) TO 1.:
us defined by,he Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Co1c,Section 25532(x)'1 VENTILATION FAN(SINGLE RCSIII)
❑Yes ❑Nopy
Will the xpplicamurfmum building.ecupantuae<quipmenlnrdeviceswhichemil
BOILER-COMP OHP OR 100.0X0 BTU) Y ANCrTyATE
h rdom air canmminanta us defined by,he Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) p�14Y 91 1995
1'Ina? 4p41f.
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.PT. 49111
1 have read the hazardous materials requirements under Chapter 6.95 of the CI1Y Ur uUYtH I IN0
Cnlil'orma Health&Selety Code,Sections 25505,25533 and 25534. I andernand,hat
ifhe building does nm currently have a mount,that it is my responsibility to n.lify Ne
ecOiNi m of the requirements which most be me,prior to ismance of a Ce sifiwte of
Occupancy.
Owner or nuthnriac l agent Date ISSIIIiD HY:
OFFICE