27344 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOII II.DING-ELEC'I'R AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27344 X44
] A A
BUILDING DIVISION - _ BUILDINIIPROJECTI0,N' ll' ."IO L 3
BUILDING ADDRESS: ' . SANITARYNO. APPFACA'11GN SUBMITTAL DATE
C!/�EF�/Alp,-Q �
Q�/00 /�ldGEUtEc�J eT Ik
Tx Lore
OWNERS NAME: PHONE: CONTjtAGf0 SNAKE �e LI/T:
/1VOEh /�F Q'�aC �C --//JJ11// LL {' VA N/C CON TROL«
�ARCIII'I'I;CT/P.N/IL N�ERC6 09044e LIC NO: ADDRESS ,0 1191u W3C-' Cn ❑
CONTACT: %U C.L.- PHONE: � . LT// hrIC
QTY. IiLECPRIC PERMIT FEE BUILDING PERMIT INFO
2q5-5-+`V/ BLDG ELECT P B MECH
C/ �G 7U PERMIT ISSUANCE g
s
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL � LOB DESCRI
QWz I herehyaffirmm
thatl am licensed under pervisioofCImpter9(commumaing with
P400 Section 7")of Division Sof Ne Buainessund Professions Cadgand my license is to PANELS /.1�^�`1 l— T
T tE full force and effect • ✓' t
zm hicenx Class Liap UPT0200AMPS
V,<0- Dom Contractor 201-INX)AMI'S
z r yr ARCIII'I'ECTS DECLARATION OVER 1111NI AMPS SQ.FT.FLOOR AREA E/SQ.Pf.
O z ai❑ I understand my plans shall be used as public records.
N
W SIGNS CLEM RICAL
axLicensed]rrorexxmnal
OWNER-BUILDERDECLARATIONthe Co ATION SPECIAL CIRCUIT/MISC.
5a0yU 1 hereby nmmt NaLI um exempt from the Conimctols License law for the
Is13�H whichingmason.
.apeatio.co365,Husineunnd Pmfdeolih,cCurb:Any city structure TEMP.MITER OR POLEINST.
%LL>-< which requiresaperminggirestepplicimprovedemolish,orrepair sayytwment
}� poortoits licensed pursuant
requires theapplicantforsuch Contractors
Licto File ense
La statement POWER DEVICES
W Oy
that heis licensedpursuantmthe provisiomeof the Ce Business License law(Chapmr
d4x CLL 9(commencing hisxempt therefrom
and the Division Sof the Business and.Any s ioli Code) SWIMMING POOL ELECTRIC VALUATION
Wim or that M17031.5 bynyap romnt f the baspernot subjects thedexempfion.Anylpar fly of OUTLETS¢ Section in)(
by hundred
doll rs($50mrti subjects the applicant to aclvll pcnuhy of FIXTURES
t morn than five M1undrcd dollvrs(ES(NB. NEW RHMDINTIAL ELECIR _SQ,FT.
WEl1,asownerofthepropeny,ormyemployeeswifhwagesaslheirsolecompensasion, STORIES 'I'YPECONSTRUCOON
a3— will Profession,
and0e is Cmarsmosin License
Law
did (Sec to W4,Business
laa ery h.1m Cale:The esfmdols nd who law such
not apply to an owner of
prupery whobuildsorimproves th<rean,anJ whodaxsuch workNmxlfanhmugh his OCC.GROUP RIS.UNITS
however,
thees,pmvldr improvement
one
earrof ca pledi n.for sawn
If,
build,, thebuildingnrimprovement ixxldwithinoneyear ofcompietion,theowner- 'I G,'AL:
builder,will have he burden of proving that he did not build or improve for purynx of
Ie J.
❑ Las owner ofthe properly,vmexdusivelycontreming with licensed conwctorsm QTY, PLUMBING PERMIT FTE FLOOD ZONE APN
instruct the project(Sec.I.,Business and Professions Code:) the Comm uses
construct
I.aw dues not apply w no awnendproperly whobudds ar improves thereon,und PERMIT ISSUANCE
whoconsracss for such projects with a eontrndor(s)licensed porsutmuothe Contraemas g1.T'Hlt-DRAIN ffi VIN'P-WATER(BA)
License Law. FEE SUMMARY
❑ I nm exempt under Sec. ,B ffi I'C for this reason l, UTSIDF.FF.F.
MUM SANITARY Y N
Owner Date RECEIPT«
. ZOO ROOF AREA.
WORKMAN COMPENSATION DECLARATION OND.
SCHOOLTAX Y N
CIfti
Iherebynred that l have a certificatett
ofcomeno self-insum,or a certificate of RECEIPT«
Workers Compensation Insurance ora certified copy theraf(See.3g(IQ Lab C.)which 5-YIiR PARK FEE Y N
overs all employee's under this permit. S-EA 5 .4 RECEIPTp
Policy X BUILDING DIVISION FF.IS
Company ASS A. If PIANCIIECK FEB
❑ Cenificl copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GR I R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' A SOILS FEE
COMPENSATION INSURANCE
('rnis section Dad Dat be cnmpinWifthepermit is forone hundrW dnllms(Eltp) wwallayalay ENERGY FEE
in less.)
I eartifythm inthe prrfonneneeofshe week far which this permit is issued,l shall TERIN.4 1TE
not employ say person in any manner so a to become subject m the Wnrkets PAID
Compensationlawsof Cnlifoodu Date WA Dam Receipsp
licant
Z O NUIICE E 'TO APPLICANT:If.after making this Certificate of Exemption. should 'MfIA
p r n,You s ou TOTAL:
1-'
becomeiwith comply
the Worker's Comms or Ihis provisions emt hall be a deemed
CMked. must
5 limhwith comply ori@such provisions or this permit shall he deemed revoked IWILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY UM r SEISMIC FEE
Z I hereby affirm that lien is a construction lending agency for the perfosmurn a of
Q the work for which this permit ix issued(Sea.3091,Civ.C.) TOTAL: i—andC FEE
Lender's Name
U L.ender'e Address QTY. . . _ MECHANICAL PERMIT FEE PLUMBING THE
1 certify that I have mad this application and state that the above information is
0. correct.lu agree comply with all cit and ordinances and state laws mlmin to PERMIT ISSUANCE MECHANICAL FEE
g pd he yon yo g
rn alanvengdanmudiogand horinspection purposes.mpmsenmtives of this city to<nmr upon the CONSTRUCTION TAX
(„) z nhw We)igree p save,indemnify and keeharALTER OR ADD TO MECH.
(We)agree a save,indemnify and keep nal,.ms the City of Cupertino against
liubilitics.judgmenm,casts and ex'isswhich may in any way accrue ugninst said Ciry AIR HANDLING UNIT(TO IO,Of10 CFM)
ivermit
a h rantit 3 9
Z / AIR HANDLING ON]]'(OVER 10,000 CFM)
Sr fApplic JC nPracmr
Dow EXHAUST HOOD rW/DUCTI PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IOg000 BTU) Date Receipt«
Will the applic.,Xrtt or future building occupant store or handle hmardous maternal
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOT�Ah:
Code.Section 25532(a)?
11Yes ❑Na VENTILATION FAN(SINGLE RESID) (ip
❑
a BOILER-COMP(TIP OR 1110,000 BTU) ISSUANCE DATE
Will the applicant or future huildingaccupanmseequipmentordevices whichemif
humnloas air contnminnnls as defined by the Be,Area Air Quality Management BOILER-COMP OVER 11X.000 BTU) � W,
District!
❑Yes ❑No NEW RESIDFN'I']AL MECH. SQ,IT, Xy�lay
I have read the hazmdous materials requirements under Chapter 6.95 of the �O• 23 V
California Health&Safety Code.Sections 25505,35533 and 25534. 1 understand that v 19
if the building does not currently have a tenant @m it is my responsibility to notify the l
capons of the requirements which must be met prim to issuance of u Certificam of
Occupancy. CItY ut Iseult
Owner m amhonmd agent Date TOTAL: ISSUED BY:
OFFICE