27227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOH¢mNc.....rRV7XL PERMIT NO. 27227
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7
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL -/7 / /
- BUILDING PROJECT IDENTIFICATION'r'" L 1 L L 1
/UIIILLDIDIIN/G_9fA_)DD9RES�S: �/- �, SANITARY NO. APPLICATION SUBMITTAL DATE
Y�"�✓� r✓�^'o�V UNIT# LOT to `1... //, �1�I
O NERS NAMEM.ntw �pHpNE; �� C Cl'OR'S NAME: CLI�NO: !Ll (/
J N/C NTROL
ARCHITF, I P.F mak— ADD7`&4//SAA .fAFM
CONTACT: {�N/� PIHONE: tK '"✓w `"M '�'-#�'g 3 13 f 7 w s v le b#
I �� QTY:; EECTRiC H MIT J. g y, KFFB f 1HUIliDINO-PERMIT INFO,-VI-Na -
00 C.�s 7, a��y//4 5_k 'r. xS a6F'.�Pr&a:s x . .. B ERCT. PLI(yfB MECH
� / I 1� ` PERMIT ISSUANCE �r (rY lyl_ �^L17�
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyz Ihereby affirm that l am llcensedunderprovisionsofChapter9(commeneingwiN
V10W0 Section] m)of Division 3 of the Business and Professions Code,and my license is in PANELS
�d� fulls nJ etl t
yZ /en Lip.#� MlUP T AM AMPS
on 6 Dam se Class /q�(( _Contract 201-1000 AMPS ,
z Ore's Z •�iP ARCHITECTS DECL RATION OVERIMAMPS SQ.FP.FLOOR AREA $/SQ.FP.
I understand my plus shall be used as public records.
SIGNS ELECTRICAL
oz�� t�
<gm' ,.'I Licensed Professional �� t7
�Ka< OWNER--UILDGR DECLARATION SPECIAL CIRCUIT/MISC. V
W' t"U I hereby affirm that I an exempt from the Commctor's License Law for the
WF 3 to-rFit following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
AV�Oa which requires a permit mconstrud.altar.improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Parnell to file a signed statement POWER DEVICES
� Q p that he is ikon.]pursuant to the provisions of the Contractors License Lnw(Chapter
9(commencing with Section 71000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
iW M, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of ATONLETS-SWITCHES-FIXTURES
QSection)031.5 by any applicant 1'or n permit subjects the.,, m a civil penalty of ✓'�
pnot more than five Imndred dollars(Sem).HNEW RESIDENTIAL ELECTR .FT.
❑ I,tsownerofthe property,ormyemployeeswith wagesestheirsolecompensetion, STORIES TYPE CONSTRUCTION
will dothework,and the strucrnre is not intendedoroffere0 forsale(See 9044,Business
and professions Code:The Contractors License Law does not apply to an owner of
property who builds m yniproves d Creon,said who d oes such work hi mself orthrough his
own employeee,dingord thatsuch improvemwthin n e year ofc completion.
foeiale.open If,
OCC.GROUP RES.UNITS
however,the bsehe brimprovementiesolde did it built of Completion,@eowner-
buildcrwill have he burden nfproving that he did nm build air improve for putphu of
Bali,) w $ v xxc+� S❑ las ownernl thnpropmty.amexdus velyeommcungwiNlicwsed contrauo m QTaY - ° �PL"UMH1N0-P T: yy`j p --�Fi FLOODZONE pPN
comwct me project(See.9044,Business and Profusions Code:)The Contractor's -
LicenseLawdoesnotapplymanowneroftimpertywhomildsorlmprovesthereon,and PERMITISSUAN 0`-
who contracts forsuch foments with awntmetor(s)Ilcenacd pursuant o the Commucmrs
License Law. ALTER-DRAIN& WATER FEE,SUMMARY" -
❑ I am exempt under Sec. ,B&P C for iM1ie reason BACK FLOW PROTECT.D ICF, OUTSIDE FEES
SANITARY Y N
Owner Da¢ DRAINS-FLOOR,ROOF,ARF, COND. RECEIPT#
WORKMANCOMPENSATIONDECLARATION SCHOOLTAX Y N
❑ Iherehyuffirmthutlhtveucutificate of consenno elf-insure,oro wrtifionlc of PfXTURF.S-PER TRAP RECEIPT#
00 Workem'Compwsetlon lnsumhw ort e,sstided espy thereof(See.3gm,1ul CJ which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT it
PelicyN BUILDING DI SION PEES
Company GAS-LA.SYSTEM-OVER4(EA) PLANCHECK FEE O
[ICertified copy is hereby famished.
❑ Candied copy is filed with the city inspection division. GREASPIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be comple¢d i f lie permit is fortune hundred dollars($100) SEWER-SANITARY-STORM EA.20al ENERGY FEE
or less)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID O
Compensation Lawsof California. Date WATER SYSTF.M/IREATING Data ei t
O7+ Applicant
z 'NOTICE TO APPLICANT:Mafter making this Certificaleof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. OTAL:
Hp) become subject o the Worker's Compensation provisions of the Labor Code,you must
a forthwith comply with such provisions or this permit shall be deemed revoked. BUILDI
z CONSTRUCTION LEN DING AGENCY SEISMIC PEE
affirm I hereby arm thatthere is a construction lending agency for the perfcrman f / ELECfRIC
U the work for which this portnu is issued(Sea 3097,Civ C) f,—,L
�#
Lenders Name
k" H Lenders Address TYa '4*4 MECHAMCAL PERMIT a FEE e 7 PLUMBIN
U 1 certify that I have read this application and spite that the above information to C*' '�r ' - `�` - "'f
correct.l agree to comply with all city and county ordinances and stare laws relating to PERMIT ISSUANCE MEC A CALF 'E
F-' building construction,anllareby suthodu representatives ofthis city benter upon the CONST CTIO TAX
�J above-mentioned property for inspection purposes. ALTER OR ADU TO MCCI{,
(We)ague to save,indemnify and keep harmless lie City of Cupertino against
liabilities,judgments,wets and expenses why mayln any wa,ro,ameagemat said City AIR I JANGLING UNI'f(TO FLOW CFM)
Inc
gramin fthia
/A��• AIR HANDLING UNIT(OVER 10,000 CPM)
SI nm ppliaam/Cpn7 m •17)ele EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS occupant
DISCLOSURG
HEATING UNIT(TO 100,000 BTU) qDateReceipt#
han
Will by the Caliamemant or uMu building Chapter 9.12,
and to Health and Salty HEATING UNIT(OVER Im,000 BTU)
al
as defined by the Cupertino Municipal Code,Chnptu 9.12,and the Health and Safety '
Code,Section 25532(a)1
11 Yes ❑No VEN'CILATION PAN(SINGLE RESID)
Will theapplicsnt orfutumbuildingoccupant use equipmenmrdevices which emit BOILER-COME(3HP OR 100,000 BTU) Isp A icl
hazardous air cohtandmts as defined by the Bay Area Air Quality Management BOILER-COME(OVER Im,Um BTU)
District, 1
❑Yes 1:1 No NEW RESIDENTIAL MECH. SQ.FT. DEC 1994
1 have read the hacurdous materials requirements under Chapter 6.95 of the
Califomia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that CII'( U GN
if the building does not currently have a tenant.that it is my responsibility to hourly he
V VU
ceptor of the requirements which must be met prior to issuance of a Certificate of
Owupancy. -
Owner or authorized agent Data - A / ISSUED-
OFFICE