27376 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELEA.FRICAL PERMIT NO.
BUILDING DIVISION APPLICAT IONIPERMIT PLUMBING-MECHANICAL. �f a �S
BUIIADNG PROJECTIDRINI IFICA'I'TON r J v
BU .DIyp ADDDDIS:I /+ �1 #ITN 10 � SANITARY NO. APPLIGTIOCN-S7U'tl/�M�`ITTAL DA]T:
O 1211'# - PHONE;: CONfRA�,]' R a___ LIC NO: NIC CON] OLIs
ADDRESS:
CONIACf: H N+ ❑ BUILDING PERMIT INFO
IRP"
sr 7� • QTY. ELECfRIC PERMIT' PP.E
IR 1 y 1 p u 12• /1-A s/1 EL6g PLUMB MECH
V1 VIeG (/'JL/I s�7/J��7f•�� PERMIT ISSUANCE � LRS•
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCR119'ION
pzZ Ihereby offirm,hm l an licensudunderproviaionsofChapsa t?hommencingwith
POO Sort.7000).f Division Sof the Business and Professions Code.and my license is in PANELS
yVU fullforecandeffect. UP T02W AMPS
t<zW License Class Lic.# `
mdy Dam Contractor 201-R100AMPS
Z FOyz ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA VSQ.FT.
p Z—M 1 understand my plans shall he used as public records. �r
L-NL; SIGNS ELECTRICAL
Licensed Professional {�
OWNER-BUI LDER DECLARATION SPECIAL CIRCUITIMISC.
OaU 1 hereby affirm that I am exempt ham the Contractor's License Law for Ne
W 3 Don following mason.(Section]031.5.Businesses end Professions Cade:Any city or county TEMP.METER OR POLE INST.
�'�' which reyuiresapermiuo connmes,cher,improve,demolish,or rep air anysmsctuce PoWGR DEVICES
aY� prior to its issuance,also requi they icant fnrauch permiuo filmP tied smmmeat
4411 ¢pz that he is liunsul pars �m m tl p sl rho Cnntnemr's Lic<nse Lew(Chaps
L QoLL 9(cu mmungwohse io ) ivision 3oftbe Busaaciotnd Profeasiore Code)
SWIMMING PoOLIi1.GCTRIC VALUATION
sy�_y onhm he ire rep t r abatis for the ellegM exemption.Any viotetian of OUTLETS-SWITCHF•S-FIXTURLS O
FZQ Semion]03 . am forepermit mbjata Ne applicanuoerivil penehy of �•
mnot more tha dollars(SSW). NEW RESIDENTIAL ELELTR S .FT.
❑ Lua owns o tepmpeny,or myemployeea with wages us thclrmlecompensatinm, Q STORIES TYPECONSTRUCTION
a willdn the work an heswcturc isnot intended oroBr.ed forsale('orA044,Busineu
and Professions e:The Comenctor's License Lew dose not apply m an s wnu of
prapeny who builds orimprova thereon,and whodaes such woh Nmulfonhmugh his
OCC.GROUP RES.UNITS
ownemployees,pmvided Nauuch improvementsare notintendedofuffemd forsale.IL
hnwevcthe building or improvmnent is sold within ane year of completion,the owner- T
builder wwill have the burden of proving that he did not build or improve for puryou of
'ale')' QTY. PLUMBINGPERMIT FEE FLOODZONE APN
❑ hes ownerofthe properSeer ,B.,icivelycainessigwitbda:)siadTh Contractor's
construct the pmjcn(Sec.]044,Business and Rofessions Cade:)The Contrvctors
Licensel.uwdaesuc apoyrowith acrofpctmod licensed
dsorimt lathe ontracors PERMII'ISSUANCF.
wbocseLaw. or such projects with econtrnemr(s)littnud pursuanuothe Contractors ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
❑ 1 am exempt under Sec. ,B&P C for this reamn BACK FLOW PROTECT.DEVICE: SID.
SANITARY Y N
Owner DamRECEIITp
DRAINS-FLOOR,ROOF,ARE-A/6911,,,.
WORKMAN COMPENSATIONSCHOOLTA% Y—N—
EI thereby affirmthatlhav<aceni0camcate ofeDECLARATION ofcanunuo self-imam,oracertificate ofRECEIITN
FlXTUHFS-PER TRAP
Wmkem'Campenamionlnsumnceified copy thereof(Sec.JgW,Iab CJ which PARK FEE Y N
rs vll employee's under Nis permit.ounit. GAS-EA.SYSTG NC.4 OUTLETS DI
RVTS]'N
Policy N BUILDING DIVISIO FEES
Company GAS- STEM-OVFA4(F3). PLANCHECK FEF.
❑ Cenifiedcopyisherebyfumished.
❑ Cerified copy is Fled with the city inspection division. 6EASEnNDUSTRL WASTE F. AOR GRADING FEE
Cliff nIgCATF.017 EXEMPTION FROM WORKERS' GREASE'IRAP SOILS FEE
COMPENSATION INSURANCE
(Dus auction need not be completed ifthe permit is fatuous hundmddollim(5100) SEWER-S ITARY-ST EA.200FT. ENERGY FEE
or less.)
I crony that in the performance ofthe work for which this Permit is issued,l shall WATER H ER ;NT/ELECfR /
out employ any patron in any manner an as to hecome subject to the Workers' PAID
Compensation Lawsnf Califamfa. Dole WATER T F-ATIN Dam Receipt is
O z Applicant
Z Q NOTICE TO APPLICANT:H,a(ter making this Cmifmateaf Exemption.you should 4ISWRPSIDF7AIPI MB. SQ. TOTAL:
is
l-� LI) become subject o the Worker's Compensation provisions ofthe labor Code,you must
fonhwilh comply with such previsions or this permit shall his deemed revoked. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of
U Or the wank fur which this permit is v aucd(Sec.300],Civ.C.) T ELECTRIC FEE
4Li F' Leader'a Name
Leader's Address QTY. MECHA PERMIT FEE PLUMBING FEE
L.) 1 unity that 1 have mail this application and state that the above information is
correct.I agree to comply with all city and county oninances and state laws relating in PERMIT ISSUANCEpass". MECHANICAL.ME
building emoinamion,and hi,mbyumhorim omn,runinw id'this city memm upon Ne
U z above-mentioned prnpeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)a to save,indemnify and keep harmless the City of Cupertino.,at.,
I itma,jud en
asm
s dexpensas whichmay in any wayacceagaimt said City AIR HANDLING UNIT(TO 10,000 CFM)
ucattogaRhiepernd. 'l
�Q AIR HANDLING UNIT(OVER 10.000 CFM)
Sign tumof APplicu A tncmr Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(70 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hamrdous material
as defined by the Cupmino Municipal Code,Chapter 9.12, it the Health and Safety HEATING UNIT(OVER 100,000,BTU) )
Code,Section 25532(a)7
0Yes ❑No VENTILATION FAN(SINGLE RESID)
will the applicant or future huildingoccupant use equipment ordevices which emit
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
• hamrdous aim conmmineres as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? B
El Yes 0 N NEW RESIDENTIAL MECH. SQ.FT. eLJ�
have reed the f,,Chazardous,materials requirements under Chapter 6.95 of the /"
if the wilding does
Safety Cntlyha ea broad,
25533andM534.responsibility
lityton of that C�/, d O
o cupanilof she requirements
which
must beme, it or my mpnce of iry m notify of r
occupant of the reyuimmems which man be ma prior to issuance of a Certificate of
Occupancy.
n
Owner or authorized agent Date ISSUED OY1J
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELEA.FRICAL PERMIT NO.
BUILDING DIVISION APPLICAT IONIPERMIT PLUMBING-MECHANICAL. �f a �S
BUIIADNG PROJECTIDRINI IFICA'I'TON r J v
BU .DIyp ADDDDIS:I /+ �1 #ITN 10 � SANITARY NO. APPLIGTIOCN-S7U'tl/�M�`ITTAL DA]T:
O 1211'# - PHONE;: CONfRA�,]' R a___ LIC NO: NIC CON] OLIs
ADDRESS:
CONIACf: H N+ ❑ BUILDING PERMIT INFO
IRP"
sr 7� • QTY. ELECfRIC PERMIT' PP.E
IR 1 y 1 p u 12• /1-A s/1 EL6g PLUMB MECH
V1 VIeG (/'JL/I s�7/J��7f•�� PERMIT ISSUANCE � LRS•
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCR119'ION
pzZ Ihereby offirm,hm l an licensudunderproviaionsofChapsa t?hommencingwith
POO Sort.7000).f Division Sof the Business and Professions Code.and my license is in PANELS
yVU fullforecandeffect. UP T02W AMPS
t<zW License Class Lic.# `
mdy Dam Contractor 201-R100AMPS
Z FOyz ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA VSQ.FT.
p Z—M 1 understand my plans shall he used as public records. �r
L-NL; SIGNS ELECTRICAL
Licensed Professional {�
OWNER-BUI LDER DECLARATION SPECIAL CIRCUITIMISC.
OaU 1 hereby affirm that I am exempt ham the Contractor's License Law for Ne
W 3 Don following mason.(Section]031.5.Businesses end Professions Cade:Any city or county TEMP.METER OR POLE INST.
�'�' which reyuiresapermiuo connmes,cher,improve,demolish,or rep air anysmsctuce PoWGR DEVICES
aY� prior to its issuance,also requi they icant fnrauch permiuo filmP tied smmmeat
4411 ¢pz that he is liunsul pars �m m tl p sl rho Cnntnemr's Lic<nse Lew(Chaps
L QoLL 9(cu mmungwohse io ) ivision 3oftbe Busaaciotnd Profeasiore Code)
SWIMMING PoOLIi1.GCTRIC VALUATION
sy�_y onhm he ire rep t r abatis for the ellegM exemption.Any viotetian of OUTLETS-SWITCHF•S-FIXTURLS O
FZQ Semion]03 . am forepermit mbjata Ne applicanuoerivil penehy of �•
mnot more tha dollars(SSW). NEW RESIDENTIAL ELELTR S .FT.
❑ Lua owns o tepmpeny,or myemployeea with wages us thclrmlecompensatinm, Q STORIES TYPECONSTRUCTION
a willdn the work an heswcturc isnot intended oroBr.ed forsale('orA044,Busineu
and Professions e:The Comenctor's License Lew dose not apply m an s wnu of
prapeny who builds orimprova thereon,and whodaes such woh Nmulfonhmugh his
OCC.GROUP RES.UNITS
ownemployees,pmvided Nauuch improvementsare notintendedofuffemd forsale.IL
hnwevcthe building or improvmnent is sold within ane year of completion,the owner- T
builder wwill have the burden of proving that he did not build or improve for puryou of
'ale')' QTY. PLUMBINGPERMIT FEE FLOODZONE APN
❑ hes ownerofthe properSeer ,B.,icivelycainessigwitbda:)siadTh Contractor's
construct the pmjcn(Sec.]044,Business and Rofessions Cade:)The Contrvctors
Licensel.uwdaesuc apoyrowith acrofpctmod licensed
dsorimt lathe ontracors PERMII'ISSUANCF.
wbocseLaw. or such projects with econtrnemr(s)littnud pursuanuothe Contractors ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License law.
❑ 1 am exempt under Sec. ,B&P C for this reamn BACK FLOW PROTECT.DEVICE: SID.
SANITARY Y N
Owner DamRECEIITp
DRAINS-FLOOR,ROOF,ARE-A/6911,,,.
WORKMAN COMPENSATIONSCHOOLTA% Y—N—
EI thereby affirmthatlhav<aceni0camcate ofeDECLARATION ofcanunuo self-imam,oracertificate ofRECEIITN
FlXTUHFS-PER TRAP
Wmkem'Campenamionlnsumnceified copy thereof(Sec.JgW,Iab CJ which PARK FEE Y N
rs vll employee's under Nis permit.ounit. GAS-EA.SYSTG NC.4 OUTLETS DI
RVTS]'N
Policy N BUILDING DIVISIO FEES
Company GAS- STEM-OVFA4(F3). PLANCHECK FEF.
❑ Cenifiedcopyisherebyfumished.
❑ Cerified copy is Fled with the city inspection division. 6EASEnNDUSTRL WASTE F. AOR GRADING FEE
Cliff nIgCATF.017 EXEMPTION FROM WORKERS' GREASE'IRAP SOILS FEE
COMPENSATION INSURANCE
(Dus auction need not be completed ifthe permit is fatuous hundmddollim(5100) SEWER-S ITARY-ST EA.200FT. ENERGY FEE
or less.)
I crony that in the performance ofthe work for which this Permit is issued,l shall WATER H ER ;NT/ELECfR /
out employ any patron in any manner an as to hecome subject to the Workers' PAID
Compensation Lawsnf Califamfa. Dole WATER T F-ATIN Dam Receipt is
O z Applicant
Z Q NOTICE TO APPLICANT:H,a(ter making this Cmifmateaf Exemption.you should 4ISWRPSIDF7AIPI MB. SQ. TOTAL:
is
l-� LI) become subject o the Worker's Compensation provisions ofthe labor Code,you must
fonhwilh comply with such previsions or this permit shall his deemed revoked. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of
U Or the wank fur which this permit is v aucd(Sec.300],Civ.C.) T ELECTRIC FEE
4Li F' Leader'a Name
Leader's Address QTY. MECHA PERMIT FEE PLUMBING FEE
L.) 1 unity that 1 have mail this application and state that the above information is
correct.I agree to comply with all city and county oninances and state laws relating in PERMIT ISSUANCEpass". MECHANICAL.ME
building emoinamion,and hi,mbyumhorim omn,runinw id'this city memm upon Ne
U z above-mentioned prnpeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)a to save,indemnify and keep harmless the City of Cupertino.,at.,
I itma,jud en
asm
s dexpensas whichmay in any wayacceagaimt said City AIR HANDLING UNIT(TO 10,000 CFM)
ucattogaRhiepernd. 'l
�Q AIR HANDLING UNIT(OVER 10.000 CFM)
Sign tumof APplicu A tncmr Date EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0(70 BTU) Data Receipt#
Will the applicant or future building occupant store or handle hamrdous material
as defined by the Cupmino Municipal Code,Chapter 9.12, it the Health and Safety HEATING UNIT(OVER 100,000,BTU) )
Code,Section 25532(a)7
0Yes ❑No VENTILATION FAN(SINGLE RESID)
will the applicant or future huildingoccupant use equipment ordevices which emit
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
• hamrdous aim conmmineres as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District? B
El Yes 0 N NEW RESIDENTIAL MECH. SQ.FT. eLJ�
have reed the f,,Chazardous,materials requirements under Chapter 6.95 of the /"
if the wilding does
Safety Cntlyha ea broad,
25533andM534.responsibility
lityton of that C�/, d O
o cupanilof she requirements
which
must beme, it or my mpnce of iry m notify of r
occupant of the reyuimmems which man be ma prior to issuance of a Certificate of
Occupancy.
n
Owner or authorized agent Date ISSUED OY1J
OFFICE