27613 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "UH, A PERMITNO.
BUILDING%DIVISION APPLICATION/PERMIT PLIIMRING-MF.CIIANICAA27613
III111.UING IBOJECT II1RN'fIF'ICA'TION
BUILDING R 5: SANI'T'ARY NO. APPLICA'T'ION SUBMITTAL DATE
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f LOT#
O NE AME: P NE: C NTRACTOES NAME: LIC NO: N/C CON'fROLM
M . S r 4
CHIT°CT/ENGINEER: L C O: ADDRESS:
qNN Glh VD(ODA LQ,17 1:1- f�
CONTACT: PHONE: BUILDING FO
QTY. a a TTR ;'IC PERMIT ' FEE. PERMIT IN
"
£c r°'` ] ) BL ELECT' PLUMB MHCII
PE ma-
LICENSED
3/ �5 PERMITISSUANCE � /
CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
pyz, lhembyaffrmthmlwnlicensNunderpmvisionsofaapeT9(commencingwith
{A 00C fall I, W1it of DIVis'lOe3of the Business soil PrnfessinnsCop,wJ my license is in PANELS sf=v �
FdU full fne end effect
'a Zu1 License Class_ Lic.M ���,���,{ UP T0200AMPS
cso
FNZ Dam ARCHITT:CT-S DECLARATION K�fe�"• OVER I"AMPS
SQ. Of IA S/SQ.FT.
Ozer'-,Q Iunderamnd my plans shal16c used ns public records.
F rn�� SIGNS ELECTRICAL V
dy� Licensed Prcfessinnul `1
aoyu
OWNER-BUILDER DECLARATION SPECIAL CBtCU1T/MISC. 71`'•1n+`
Oy I hereby affirm that I am exempt from the Commmors License 1<w(or the
ad+: y following reason.(Section 7031.5.Business and Professions Code:Any cityorcounty TEMP.METER OR POLE MST.
"� which requires a permit m centuries,alter,improve,demolish,or repair any structure
`WW°Y� prior its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
HW P:<Oz tem
Fiat he is licensed pursuant to the Provisions of the Commar s License Law(Chapter
o-Xo19 9(commencing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ly—y orthat oheisexempt byany mfromsand fee a besiafor bjthe
ctsalleged exemant to civiny l
of OUTLMS-SWITCHES-FIXTURES I ��
C Secunonsownby manduali6.11 fora Permit subjects the applicantmactvil penalty of L
❑ tan ethnn Eve htmdreJ dollars(SS(l0L NEW RESIDENTIAL ELECIR SQ.IT.
m trial pmperty.miry employees with wage,as tnsi,,alecompematlen, STORIES 'IYP.CONSTRUCT ION
2 _ will do the work,and fiesm,cmre is notimendedoroffnod forsale(Sm.]044,Business
and Professions Cale:The Contractors License Law does not apply to un owner of
property whobuildsnrimprovesthereon,and whodteeaach work himselforthroughhieOCG GROUP RES.UNITY
own employees,provided that such improvements are not intended or offered but If,
however.the building or improvement is sold withinone year ofcompletian,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
ate.).
❑ h asownerofthe property,amexclusively contrectingwith m
licareademurremm QT'Y3 PLUMBING PERMIT FEE FLOOD ZONIi APN
cnnswn the project(Sec.7044,Business and Professions Code:)The Contractor's
License Uhwdous an apply uh an ownmofproperty who builds orimpnwes thereon,anti PERMIT ISSUANCE
whocnnmact,for such projects with a commirsr(9)licensed pwatemrto the Contractor's ALTER-DRAIN&VP,NT-WATER t
Liunw Luw. (h FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y DEN
Owner Date DRAINS-FLOOR,ROOF,AREA,CO RECEIPTA
WORKMAN COMPENSATION DECLARATION SCIfOOLTAX Y N
❑ Iherchy affirm thetlheve aceni0cnte of consent to xdf-insure,ora ccrti0cete of FIXTURES-PER TRAP RECEIPI'p
Workem'Comparnewhn lmuraneoracrntred copy drawaf(Sec.3800.lab CJ which PARK FIB! V N
covers all employee's under this penna. GAS-EA.SYSTEM. INC.4 OUTLI?T 11 EIPT a
Pal lay# BUIL DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 EA) PLANCHECKFEL Q
❑ CC dificl copy is filed with tishW.
� Cenilicd copy Ta filed with the city inspection division. GREASP/INDUSTRL WASTE INTERCEPTOR TRADING TZG t sit
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS FEF.
COMPENSATION INSURANCE.
or lesGhs section need oat becompleted Btwpermit is forouehundml dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGYPEE kk) inO
I unify that in the performance ofthe work fn-which this permit is issued,I shall WATER 11hTER W/VENT/F.L.ECTR
not employ any penton in any instance so as to become subject to the Workers PAID
O z Compensation Laws of California. Dote WATER SYSTEMITREATING Ume Receipt
Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
1-^ � become subject m the Workers Compensation pruvisiorm of the Labm Cale,you must
� > forthwith comply with such Provision.or this pcmanhad be deemW revoked. BUILDING HEC166 —
aA CONSTRUCTION LENDING AGENCY SEISMIC FEE
'J z Ihereby effimt thatherc is acomurmadon leadingagency for the performemil
U O the work for which this pcnnit is issued(Sec.300,Civ.C.) T '� ELEMIC IEE
Lender's Name PLUMBING FEE
U.F Lander',Address QTY. MECHANICAL PERMIT FEE
V I certify Nat I huvc read[his application end storences tie shwa information is
�" W) building
lagree mcomply with allcity countyordinancesofand stets lawsralmings,
upon gm PERMIT ISSUANCE MLCHANICAL FEB
F-' Z buildi-memiowctinmert hereby rehearse rp ses. es ufthis city reenter upon the CONS'IRUCI'IONTAX
U z aMv(We)swo, .sa,a,y for Tmpect nd Purposes. i ALTER OR ADU TO MECH.
(We)ugree to save,indemnify and keep harmless the City Of Cupertino against
incontsequece of da,cvsband cxpcnsearrah. mayinany way azcrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
consequence of the granting of thks Permit.
AIR HANDLING UNIT(OVER IgWO CFM)
Signature of Applicam/Contmcmr Dan EXHAUST HOOD W/DULT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data t
Will the applicant or future building occupant store or handle hewNous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino MumcJ'pa]Code,Chapter 9.32,and the Health and Safety
Code,Scotism 2553200? / (•
❑Yes IJVI�. VENTILATION FAN(SINGLE RPSID) bQ vV
-I^SSUANCBDATE
Will the applicamnrlumrebuddiI "'cupnnt meequipmemordevices whichemit BOILER-COMP(3111'OR 10),000 BTU) �wo`'\ r.�-s,
bazardou.air contaminants asod ed by the Boy Area Air Quality Management BOILER-COMP(OVER 100,000 B'ID) \ � \ ,. e
IshiCIT
❑Ve. NEWRCSTDENTIALMECII. SQ.FT. APR 24 1995
L have read the hi awderm materials requirement, oder Chapter 6.95 of the b
Caltnmiallcalth&Safely Cod ectiums25505, 33 125534. 1andmitandthm C'If
if the ' gdces Curren hav tit' yreance,of.Carnmtfy the V 1 U�- (�U�t Na�{njr-T1
if ant yuircado nmet P' m issuance of it Certificateof
he
�^
m ISSUED BY:
e
OFFICE—
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