27585 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11-D1Nf'-Kt.KUFR ' PERMIT NO.
BUILDING DIVISION APPLICA'T'ION/PERMIT PLUMBING-MECIIAN'ICAL O C
BUILDING PROIECIADEN1'IF'ICATION o J
BUILDINGgDDRFS9S:2 �J �s�../ 'r SANITARY NO, APPLICATIONSUBIAMALDATE
9/ ✓Z /w UNIT LOTM \2�
OWNERS ME: PI{OHF.: PACT 'SHAM LIC NO: N/C ` CON'fRO/1.N�
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AHCIIITP.CT/E GIN.LH: ej LD �
IC NO: JU
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CONTACT: PHOS .
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Q'PY. ELECTRIC PE MIT FEE BUILDING PERMIT INFO
—� PERMIT ISSUANCE BLDG ELECT PLUMB MECH
r _
LICENSED CONTRACTOR'S DECLARATION ppPLIANCES-RESIDENTIAL JOB DESCRIPTION
KZ Ihereby 7")affirm NeH amlicensed eosins dIrv,onsions Code,and
my ansin,brie with
0{�0❑ Sectioneun)ofectviaion30(Ne Business and Pmfessions Code,end my ITcrnse is in PANELS
ftUU fill fareClas effect UPT0200AMPS � • Y"r�
GG ty License Class Lic.p
vFi=y Date Caaacoor 201.1000AMPS
Fyz ARCHITEC!PS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
Z0,6— I understood my plans shell be usedmpublic records.
I"AMPSOZ—M
4YL:� Licensedprev'sn nal SIGNS ELECTRICAL
K
OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC.
OyF I hereby affirm that 1 am asomp,exempt tram the Conanctob License law co the
W 3Oq fallowinguiresa permit
tocons.S.Buainev and Professions Can.:Any citystructure TEMP.METER OR POLE INST.
Sys which requisaapermit re consww,aper,improvgdemaon t or file.dr anyyummand POWER DEVICES
Y�
man lie
slicensed puralso
uant to the
the
Proisionsmfor thesuch Co peactors icese Law(tament
�p 9(c(commencing
ncing with Section 7")of
Provisions n the Contractors and
xlsions Co ter
9(tat he is ixemith5ewiism,an the bisision3ofthe Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
t_y Sethi 7031.emponyappomnt f the PeriaI subjects
the app,exemption. civiny tPnatyolation of OUTLETS-SWITCHES-FIXTURES
Z Q Section]031.5 by any applicant for a perma the ePP' t to a civil pmdry of
��O not mare than five hundred dollen(f5lp). � �1
K m ❑ I,mownero(Ne propeny,armyempliN ga®th nolemompcmadan, NEWRESIDENTIALELECTR _SQ.FT. $TORIES TYPECONST1tUCfION
will do the work,andthestrowumis not imeeredfarsale Sec.Bad.Business and Profess an Code:The Counse s LLaw does net n ly to a owner of pmPenywhobuildsorimproveathereon as tach workh selforthrougbhisOCGGROUT' RF.S.UNITS
ownemployees,providedtlmt sue rovere not int ended offered forsale.ILhow er,the building ter ement is soln one year ofea plelan,theowma-
builcrwill Im uNenof proving thanot build m Tm nve for purpose ofs le.).1,nsowne ofthepmpeny,nmcxdusitrectingwithlic and contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONL APN
ronswctthep bet(Sec.]W4,Businessions Cale: TheContractorsPERMIT ISSUANCE
lice. lawdcw mapplya owne fh dswim es Nereon,and
whocnntncn fm su projau i iarwet anus eConbectors ALTER-DRAIN&VENT-WATTi0.(FA)
1 ic<nu law. FEE SUMMARY
❑ 1 um exempt and Se ,B&P C for this teawnp ES
BACK PLOW PROTECT.DEVICE SANITARY YN_
Owner Data RECEIPT#
DRAINS-FLOOR,ROOP,ARFA,COND.
WORK AN COMpE TION DECLARATION SCHOOLTAX YN_
❑ hunchyaffrmthatl es..ccri amofconsenttoself-insum.orecertifceteof RECEIPTp
PIX'IVRPS-PER TRAP,,r' ' "rvs
nrkers'Compensation) umnce ii.iifiedcopy Nemof(Sce.3800.Lab C.)which PARK FEE Y N
covers all employee's and Nis noir. - GAS-EA.SYSTEM-1 INC.40UTLCTS ) RLCEIPTk
policy M UIL NG VISION FEES
Company GAS-pn_cYsrEM-O R ) PLANCt
❑ Cer ificd e.,k hereby famished. (f— s 1
❑ Certified copy is fled with the city impation division(' F. f GRRASP/INDUSTRL RC11Mi GR aFE 1 ��
1
CERTIFICA MPENS TIONI SUFROM AN WORKERS' GRfASF.�N Yt SOI F
COMPENSATION INSURANCL'�
(This sation need nm becomplctad if Ne permit is forow hundred doll Os(>I00) E F.R-. 1 - T R IA.2 kJ ENERGY FEE
nr less.) m O
Icenify that in the performance of the work for which Nis permit l issued,l shell HENT/1?LECTR �j
not employ any person in any manna m m m become subject m Ne Worki N ' PAID
Compereadmi laws 1'Califamie. Data WATER SYSTEM/TREAT 1;G W p_ Date
p Z Applicant x:. n.,
NOTICE TO APPLICANT:If,after making this Certificate of Eaem tin .TOTAL:
'z „--� p o,you Nould ,NEWRPSIOFNTIAL PLMR. SQ.FT.
r rA
become subjatm N<Wohets Campenvtiwmprovitiom of the latigr Code,youmms•
� > forthwith comply with such provisions or this permit shell be BUILDING BUILDING FEE r-e
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Q
^a I hereby affirm that them is a construction lending agency for the performance of
V O the work for which this Perm is issued(Sec.301 Civ.C.) 1 f?LBCfRIC FEB `
t,2. Lender's No=
O Lmolm's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I minify Net I have read Nis applie ion and state Nat Ne abase infwmatie r is
QW-, cormco.Iagmemcomply with ell city erdcounryoninancesand some laws mlatingto PERMIT ISSUANCE MECHANICAL HE
F" CA building construction,and hereby auNorua repasenntivesof Nisciry memeruponthe CONSTRUCTION TAX
U Z above-memioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap hamdess the City of Cupertino agaimt
l ubil'nies,judgments,cosnand expenses which my many ways meegeimtssid City AIR HANDLING UNIT(TO 10,000 CFM)
seyueoce of Ne gm ffle", this pe AIR l{ANGLING UNIT(OVER 10,000 CFM)
Tlarthre Ap c r a F.XHAUSTHOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10100,(100 BTU) Data fteceiptM
Will the applicant or future building rampant store or hardlc airstreams material HEATING UNIT(OVER 100,000 BTU)) TOTAL:
as refund by the Cupertino Municipal Code,Chapter 9.12,and Ne Ileatth and Safety
Csde,Sectori 2553Ha)7
ElYes El No VENTILATION FAN(SINGLE RESID)
❑
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Will air commitments
as defined
b cthe Bay Area en Quality
Manage ant gry A
rordom air comnminums us defined by the Bay Area Air Quality Management BOILCR-COMP(OVER IW,(100 BTU) 1�
triwP
❑Yes ❑No NI?W R12SIDEWTAL MECH. SQ.FT. ��� _7
1 have read She bamrdous materials rem
quireem.under Chapter 6.95 of the 1995
California Health&Safety Code,Sections 25505,25533 and 25534.1 undersand Nal '
if the building does not enormity have.tenant,that it is my responsibility to notify the C'n OF f
occupied of the requiremems which must be met prior to issuance n(a Certificate of
Occupancy.
Owner or authadaed agent Date 't. ISSUED BY:
OFFIC