27237 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOmDINU-KI:ECTRrCAT PERMITND.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJEC'1 DENT WICAT'ION
BUILDING ADDRESS: 27237
� ���C.o esti SANDARYNO. APPLICKDONSUBMITfALDATE
lracK 103qUNIT# LOT# 6t i0-�s-�
OWNER AME: PHONE.: CONTRACTOR'S NAME: LIC NO:
Dey . N/C CONTROL#
7 IVH7� pulse✓
\RC1 TECf/EN'INF. : ` aMe�.I NO: ADDRESS: ❑
ONTA /I- �^ PHONE: BUILDING PrRRMIT I �O
�sfeti Han ,p QTY. ]ELECTRIC PERMIT FEE
/ ?79- vi BLUG ELECT PLUMB MECH
`4 n PERMIT ISSUANCE f� M IFA El
EN
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDTIAL yA 1COB�DFSCRIPI'IU 04N
pyZ I herm
hereby offinhat l am und
limmoderproviaionsofCbapur9(commencingwith
La100 Fahon]f100)of Division Sof We Business and Professions Cede,and my limrsse is in PANELS 7� t /��
C V 1- full fmce and offal. .1/.._ W
<N Licenu Class Uc.# IIPT0200AMPS
vaQ y Date Conlrecmr WI-1000 AMPS
FyZ_ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA VSQ.FT.
OZ`np I understand myplenv shall be usedupublic reeoNa. OVER 1000 AMPS / -
rooi tW SIGNS ELECTRICAL 6
.30 L✓. r 0
Licensed Professional 3
eeJ�a'Q OWNER-BUILDER DECLARATION SPECW.CIRCUITMISC. -70 �� �-aQ7
KO y V 1 hereby affirm that 1 am exempt from the Conuenore LicenseLaw for the
• _
W 3 LL y following mason(Seninn 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST. �
F'uJ which reqm requires a permit consuum,titer,improve, mo
delish,ar repair any,.mto
ute 0 22-JI
Cn}7 priono its lssuance,idmoo,uirtnheapplica tfm,arh period a file esigned statement POWER DEVICES /� ��� a 6a
ly E;nQp
that he is licensul pumuam mthe provisions of the Contrecbrs Licen (Chapter
4 9 mmencin Ih Section 7fNIB IfDivisinnJof Ne Business an (asst ns Code SWIMMING POOL ELECTRIC
o gwi �$3 s� 7
' .,y onhat he is exempt thercfmmand the busie fur the alleged sae VALUATION
tors.Any vin tion of OUTLETS-SWITCHES-FIXTURES
4 Section LS by any epPliantfor a Permit subjects the montmacivil pe ty of
nmorc than fivehunJrcd dollars($5(h0). NEW RESIDENTIAL ELECfR _SQ.ITf.
p� p
nor
I,esownero0heprnperty,ormycmployas wagesastheinolecompensat n, STORIES TYPE CONSTRUCTION
yo0 wilidmhc work.and lhcawcmrcisnrn ism oroffemd for sale(Sm.7044,Basin s
f2eI 6-2-
end Professions Code.The Contract .irem.Law dos not apply to an owner o
,moo,dywhabuildsorim eocon,andwbodrossuchwmkhirrselforthroughhie OCC.GNOUP RES.UNITS
nemployma,powided haunch improvemeatsam not intended conflicted forsale.If,
however,the buildingar i provement is sold within one ye.,Vfcodip ii ,theowner- O
builder will have the hot of praying that he did not Id W.h�i eve for purpose of
1') C QT PLUMBING PERMIT FEE FLOOD ZONE APN
I,ea ownerofthe pmpe y,umexclan'"y Ij'aGu Tic<®ed connote to
cmnseuct the projem LSec.7 ,Business ns Code:)The Com to'
License Lawdcesnmupply too o erof pro h uidsmimproveath d PERMIT ISSUANCE
whowmrainforsuchprojectsw w cones torp icon. pursuanuoth coo
License Law, c s ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
❑ Iam exempt under sec. ,B Cfor this reason BACK FLOW PROTECT.DEVICE SANITARY YIDDE N
Owner am DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT.
W0 KMAN COMPENS 10NDE RATION SCHOOL TAX Y N
❑ Ihemby affirm lhv lhevcacmificnma on ue ulGinsurt,orattrti0cme of FIXTURES-PERTRAP RECEIPTp
Wmken'Cmn1mation lnsunnce ora certified ydoteof(Sm.3800,Lab CJ which PARK FEL' Y N
coven all employee's under this permitGAS-EA.SYSTEM-I INC.40fT1'LETS RF.CE1PTp
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4(EA) PLANCHF.CK ME .,z�
E) Certified copy is hereby furnished. z .?Q
❑ Certified copy is filed with Joe city impeetan division. GRRASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEEO0
COMPENSATION INSURANCE a
or
(This section need not becoinpleud iflhe Permit iv Intone hundred dollars(SIM) SEWER-SANITARY-STORM EA.201 ENERGY FEE 2-`O
Ittrtify Netin Ne performenuef Ne work for whichthia penniliv iuued,lshdl WATER HEATER W/VENT/ELECTR
Comnationn el fo y'm Dacr so m ,Su��$/,tq the Workers' WATER SYSTEM/IREATING PAID
o z ,r Y �Y/-7 Y Data Pl#
Applicant
z0 NOTICE FO APPLICANT:If,sher making this Cenificeu of Esersxi.n.you should NEWRESIDENTIALPLMB. SQ,FT. TAL:fCf a3t7
� U) become aubjxtu the Workers Compensation proviia.of the labor Cod..you must
Ki , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDIN FF k60
CONSTRUCTION LENDING AGENCY
z I hereby affhm that there is a construction lending agency for performance of
the work for which thignnil isissued Sec.3097,Civ.C.) L.
CLT: liC
45. � Lender's Name./0K�!
O
Leader's Address 1 QTY. MECHANICAL PER FEC PLUMBING PEI
U ±
U 1 certify that 1 have rutl this application and auu that the above information is
wmect.(agree to comply with nll city and county oNinenttsend mom laws relating to PERMIT ISSUAs MIiC11ANICAL
�-' V) building construction,and hereby euthmira representatives oftbis citymenter upon the CONSIRUCI'ION'fA
U y above-meminned property for inspection pwposes. ALTERORAD TOMECH.
F7 (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs undcrpenses which may inuny way accrueagainsl said City AIRHANDLING IT(TO 10,000C ) #
in consequence gmnl' gof hhks Permit,
AIR HANDLING U O E 1 0 FM)
Signamrc of APplicen4Comnamr (late EXHAUST HOOD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I 010BTU) Dam --lot#
Will the applicant or future building c.print vont or handle haeardou t mmeriel
as defined by the Cupertino Municipal Cade,Chupur 9.12,end the H.1th and Safety HEATING UNIT(OVER 1 000 BTU) TOTAL:
Coda Section 25532(a)1No VENTILATION FAN(SING .RfSID)
❑Yes
SUANCE DATE
Will@eopplicenw
l or builJinBnccuPanmum eyuipmeordevica BOILER-COMPLIHPOR1 MOBTU) P' R
whichcmit sv 1 {J
rdom air contaminants M defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100, BTU)
isP No 13 Yes NIEWRESTDFNGIAT MECH lisz SQ.PI'. FEB 151995
1 have read the havudous materiels requirements under Chapter 6.95 of the CITY
California Health&Safety CMI.Sections 25505,M533 and 255]4. l undersand that CITT I or VUT,tK l
if the building does oat c...fly have o unam,that it is my responsibility to notify the I
al
occupant of the/rt/quf¢J"�ems wh�'cM1^(fhfs�h�e�eatp�or to issuenc</7�oQC.ttJyficn�u/of
Occupancy.Ono.croarrarliumozerigern Dau /—
�„ ISSUED BY:
OFFICE