27872 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT,INO N RAH G-ELLCI'RI AI, PERMIT NO.
BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING-MECHANICAL, 27872 7 o 82
7 BUILDING PROJF,CTIDENTIFICATION G L
BUILDINGZADDRESSo?d8: UNIT LOTH 1 SANITARY NO. APFLpcNnoNSUBMU7ALDATE
Y .�OWNF"R *. — CONTRACTOR'S NAME: LIC NO:
NA] CON' OLN
NCIIIT. /WN i13N: LIC NO: ADDRESS: ❑ Q
CONTACT': CO/`N BUILDING FO
`
QTY: ELECTRIC PERMIT FEE PERMIT IN
/•Ajr pP� _
BLDG PLU H
L✓� PERMIT ISSUANCE
LICENSE13 COM'RACIOR'S DECLA ON I OCZ I hereby affirm that I=licensed under envisions of Ctcr9(commencing N APPLIANCES-RESIDEN'TIAL
JOE DESCRIPTON
LL00 Scction]IXM)of Divixinn3of she Business end Professions Cale,end my license isin PANELS
fF�-V full force and effec
¢Z License Class Lic.Moiq 62,33 UP T020f1AMPS 1
v~s Q of Date Contractor 201-1000 AMPS v
Z pyZ
ARCHITECTS DECLARATION OVER IgIf1AMPS 1p SQ.FY FLOOR ARBA f/SQ.FT.
OZ—t] lundemnand myplanssholl he used.,Public recmdx.
Fyt; SIGNS ELECTRICAL
Qy�M, Licensed Professional
�y�ua'1m 6 OWNE ILDERD LARATION SPECIAL CIRCUIT/MISC.
qx 0yU I hereby affirlot b , exempt from h e Conimctors License Law for the M�
u13
U.t; followingrcaxoa(Se t7031.5,13usmeaund mwi.ns Cude:Anyeityurc.md, TIiMP.]ALTER OR POLE INST.
t E:0� which requires. it to construct,alter,impr e,demolish,or repair any,tmetum
�Y� use,also re the applicant Permit to POWER DEVICES
pnur quires PP P< B
W qO also
he xlicensedpuou Sccmr700T.doiffie Dh,hsnfth he
shiit Pro Lass iorm Coser
2 od' 9(c. encingwiN Sechi.n]000)of Divisinn3 hhc Rosiness anJ professions Code) SWIMMING POOL ELECTRIC VALUATION
W .,that eisex ur uhemlromandlhebad,fnrth aIle edesent i An I t f �1 ?� �[(D , 3 3
—,� e p g pton. yvi..ltyo
G Sccti 9011.5 by any applicant fornpctmit subj tithe appiicunnoacivil Penalty of OUTLETS-SWITCHES-FIXTURES
neem m than five hundred dollars($500).
C1 as
C � ownero0he propm .rm
y, yemployeee ithwagesastheirs.lecompensanNRW RF.SIDIiN'HAI.ELECTR _SQ.FT.
.n, S RIES 'IYPECONSTRUCHON
y322 will thework,andthestrai 'tnendW0 offered focstle(Seo.90a4,Business IAOLS'�6 ii
and "Nssions Cale ITe C thsn r Lie aw does not apply W an owner of
pro, nywhtbuildsor P I .qundwhossuchworkhinoself.lhomghhis
employ s improvements en intended!or offered Rustle.If, OCC.GROUT' RES.UNITS
hot r mpr.vementissoldwithi neyearofcompletion,the owner-
buil err Ia burden of proving then h d not build or improve for purpnxe of
sale
❑ mo offfiepro,emy,amex sivelycortmeting with liunscd<ommnorsto QTY. _ PLUMBINGPERMIT' .. FEE FLOODZONE APN
constm the project(Sec.](144, dress end professions Civic:)The C.chactols
License nwd.esnouhpplymah runuTopedywhobuildv, improveehhe and PERMIT ISSUANCE
wha cont,nsforsuch proj withecon0uctorts)licnncd pursunmmthe ahem° ALTER (FA)
Utica.La FEE SUMMARY
❑ lam ex s at Sec. ,B& for this mason BACK FLOW PROTECT'.DEVICE SANITARY OVISID['FEES S N
Owner z¢ DRAINS-FLOOR,ROOF,AREA,COND. RECEIPI'g
WORKMAN COM ECIARATION SCHOOLTA% YN
❑ Ihemhy affirm then lieu imam of c.nscnuo self-insure,orac<niiicme of pl%TURF,S-PER TRAP RECEIPT
Workers'Comers ke l ante or a wnilied copy Nercof(Sec,3800,Lab CJ which PARK FEE Y N
coven all employee's der Nis pchmih. GAS-EA.SYSTEM-I INC.4 OUTLETS REC&PI'M
Policy g BUILDING DIVISION FEES
Co any GAS-EA.S Y$TEhf-OVER 4(EA) PfANCHECK FEE /0--70
Certifluico ishembryfnmished.
Certified co yis filed lh the cityshe it i. a. GREASEENDUSTRL WASTE INTERCEPTOR GRADING FEE
C RTIFICA ONN11 fr,(^('��f,,''RK' GREASEI'RAP SOILS FEE �J
C ' A'ION URAI)Qj�,un J
or less�wsecmon eednm pletedI pe ff,.�llpp�y//tt d l.n(fI W) SEWER-SANITARY-STORM EA.20017. ENERGY FEE 72e
60
I cenify that in ho. on : c.f Ne or for which this permit is issued,I shall WATERIIEATERW/VENT/ELF:CI'R
not employ any M ua in it manner m d m bccome.subjen to the Workers' PAID
Compensmion Laws fColifom., Date / ' WATER SYSTEM/IREATING Date R.iphWi
O z Applicant
z0 NOTICE'I'OAPPLI NT:ILarmrmokie,thisy�.``'n ideate of Exemption,you should NEW RESIDENTIAL PI,MB. SQ.FT. TOTAL: Tl
FI/J become subject to the orker x Compensshin P(ovisi.ns of the labor Code,you mush /V
a ; fonM1wiNcomply with uch provisio ort ((permit shall be deemed revoked. BIT FEE 2 L
W z C NSTRU,n'N LENDING AGENCY SEISMIC FEE
5 1 hereby affirm Na there' construction lending agency for the perfommnce of
U O the work for which this it is issued(Sec.3097,Civ.C.) 'I ELECTRIC FEE
w ,r lender's Nume r r' PLUMBING PEE
Iznder',Address QTY, ' ;MECHANICAL PERMIT HE
0 U 1 cenify Nat 1 have reed this epplicmich and ram that the above information is
U) correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MSCI IANICAL FEE
F^ N holding amsbuctinmamd Immbyinquir erepmsemntivcsofmis city toenterupon the CONSTRUCTION TAX
U Z .tine-mentioned properly for inspection purposes. ALTERORADDTOMECH.
We)agree m save,indemnify and keep harmless the City of Cupertino against
li ilit .judgment. cwt,andesperues which may in any wa eccmeagainst said Ciry AIR HANDLING UNIT(TO 10.000 CFM)
Icons yuence ft �ng oft is pemhil AIRHANDLINGUNII'(OVER I0,000CFM) O
Stdidired
nature(if Ap' hV nmhctor Data EXHAUST HOOD(WIDUQ) �..-/Q fj�O�by� z4
PAID �A 3
HAZARDOUS AERIALS DISCLOSURE HEATING UNIT CID 100,000 BI'U) Dae ReceiptN
Will the applicant.,(mem bait oxv.pardsmarmhandleharallom material BE ATING ONITUVER 100,0100 BTU) TOTAL: � 1
u by the Cupedino Muniripo Crile,Chapter 9.12,and the Health and Safety
Glide,Section 25332(u)7
11Yes 11 No VENTILATION FAN(SINGLE REMO)
❑
BOILER-COMP(3HP OR I00,0M BTU) ]SA AN"N'
Will the applinmt orfmure buildingoccupant useequipmem nrdevices which emit ]SPA
"40barurdous it contaminants us defined by the Bay A.Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Dishier] MAY 191995
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hsrardous materials or,mocments order Chapmr 6.95 of the
California IIeahh&Safety Code,Sections 25505,25533 and 25530.I undectmil then CII Y Ur wf CtfIINU
if the building does not currently have a tenant,that it is my res,msibiliry in notify the
occupant of the requirements which must bo met prior to issuance of a C nTcim of
Occupancy. Jx
Owner or am.rir
het agent Dole T 'Aljt) ISSUED BY: 5s" �Q�
OFFICE