27297APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATIONIPERMIT
.R 11131Ri'-ELrCTRT
PLUMBING -MECHANICAL
' INILDIN(i PROJPI(TTII)FN'ITIBO
(:A'1TN
PERMIT NO.
%�(�
G J
BUILDING ADDRESS: / //'' �iI, n
.YLLI'N 1O `^-'�DNI�1`- LOT#
SANITARY NO.
APPLICATIONSUBMITTALDATE
�\ /
L Y L
OWNERS NAME: -I �� P Oyyl?p
[b/l6
C( C'fOR'S NAME: r LIC NO:
NIC
❑
CONTROL#
ARCHITECI'4iNGINEER: LIC NO: ADD W:
l — J
7 76 J
CONTACT: PHONE:off,�'Yf6%iy:
/-� �7 �(Y7
(f ! `
QTsY? v$�y}{ELEGTRIC PERMITa^ FEE "'
P�"�mvffa`�ee 3't w`'"r'- 5
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l tun icensed underprovisionsol'Chapter9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Swim 7000)af Division 3 ofthe Business and Professions Code,andmy license isin PANELS
fall Licernree and effecy� � � �s
j License Class come— iap a+ UP T0200AMP5
Date Commcmr
Lot -1000AMPS
SQ. Ff. MOOR AREA
$/SQ. Fr.
ARCHITECPS DE LA ATION OVER 1000 AMPS
1 understand my plans shall be, used u public records.
SIGNS ELECTRICAL
LimnsW Professional
OWNER-RUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractor's License law for the
following homm. (Section 7031.5, Business and Professions Code: Aay city or county
TEMP. METER OR POLE INST.
which requires a permit ,, construct, alter, improve, demolish, nr repair any structure
prior to its issuance, also requires the applicant for such permitto file a signed statement
POWER DEVICES
(hut he is licensed momm, an the provisions of he Contracmds Limme Law (Chapter
9(commencing with Section700o.fDivision 3o171he Business and Profeasfon Code)
nr that be is exemptahereframaM the basis fnfle.11c,pl exemption. Any vidiameof
Sutim ]031.5 by anyapplicant fora permitawbjm. the applicant toa civil penalty ofElnot
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTUR*3A
VALUATION
mare than five rofthe died dollarmy emy
❑ wnnafthepmpertyre
NEW RESIDENTIALELECIR
IP 'TYPE CONSTRUCf10N
othe
dothework,andthe swucomIsnot inLicense afferes]wdo fo (Sec.]044,
Iso intendecswitbwegnasthei(Sm. 044, Bnsafion,usiness
and am
not apply to an owner ofproperty
obs CWe: TM1c Contractors License Lew
weer ofend Pfty
wh uch i
who buiIdsorimproves thereon, end whodoes such work himuIforthroughhis
CC. GROUP
RES. UNITS
eomloyees,prnvidW ihateuchimpmvememsate nntinondeA uroffered farsale.IL
however. the building or improvement is sold within meyearofcompletion, Ne owner- builder will have the burden of proving that he did not build or improve for purpose ofsolo)
❑ Lnow props (Sm. 7044, euro ss and Profe sits with de:) The Cin a t
nevem the project (Sec. ]044, Bermes end CWep The Commcmrs
QIYi . -PLUMBING PERMIoo.ZDNI:
k
APN
ywho bons
Licenc Lawdcesnot applytoenawnernfproperry who buildsorimprovesthercan,end
PERMITISSUANCI?whocntioncts
frsueh pmjmN with ammuctr(%)IleensedpursuanttoiheConlractur's
Law.
ALTER-DRAIN&VP.NT-WATI?License
FBI? SUMMARY
❑ I to. exam,( under Sec. , B & P C for this reason
BACK R.OW PROTECT. DEVICE.
OUTSIDE FEE'
Owner Date
SANITARY YN
RECEIPT'#
WORKMAN COMPENSATION DECLARATION
❑ l hemby affirm that l have acetifinete ofmosenno self -insure, or.cetificamo(
l Cnmpcnsatianlnsumnce orucertifiedcopy therrof(Sec.3gm, Lab CJ which
DRAINS- FLOOR, ROOF, AREA, COND.
FIXTURES - PER TRAP
SCHOOLTAX Y N
RIiCGIPTN
PARK FEE Y N
covcovers ally u e yc
ol Cy#ler9ppQr �3�i�TA' r
policy//VV,U(�c/j'I
CAS -LA. SYSTEM -1 INC.40UTLLTS
RECEIPT#
BUILDING DIVISION FEES
Company fIJ/�!
GAS-PA.SYSI'EM-OVCR4QiA)
PLANCHECK FEE
❑ Coro'eJ co -,
py is hcrchy famished.
Certified copy is filed with the city inspection division.
GREASHoNDUSTRL WASTE INTERCEPTOR
GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
GREASCTRAP
SOILS TTI:
(This,cmion need not be completed if Ne permit is formo hundred dollars($100)
or ins.)
SEWER - SANITARY - STORM FA. 200E7.
ENERGY ITE
I ondify that in the performance of the work for which this permit is issued, l shall WAT17R HEATER W/VHNTTLECTR
not employ any person in any manner so n to become subject to the Workers
Cmu,samationlawsof Culifnnia. Dao
Applicant
WATERSYSTEMMEATING
PAID '
pate Receipt,
NOTICE'TO APPLICAN".If. after making this Certificate of Exemption, you should
become subject o the Workers Compensation provision of the labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
foMwith comply with such provisions or this permit shall be deemed revoked,
BUILDING FEF.
CONSTRUCTION LENDING AGENCY
SEISMIC ITE
1 herchy affirm that there is a conduction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
TOTAL.:
ELECTRIC PEE
Lenders Name
- '
LenaerhAJdress
x , y . p •-
QTY.1"; �=MECI IANICALr ERM41T FEE
PLUMBING PEE
I certify that I have read this application and state that the above information is
MECHANICAL TRE
count l agree to comply with all city and county onimnces and more laws testing to PERMIT ISSUANCE
building concoction, and hereby romance representatives of this city banter upon the
above mentioned property for inspection purposes.
ItCONSTRUCTION
ALTER OR ADD TO MECH.
TAX
(We) agree m save, indemnify and keep harmless the City of Cupertino against
-
habilllies,judgmems, costs and expenses which may in any way acerueaguinsl said City
AIR HANDLING UNIT G 010,000 CFM)
in consequence of the granting ofthis permit.
AIR HANDLING UNIT (OVER 10,000 CPMI
PAID
Signumm of ApplicanUCanlmaor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO I00.000 BTU)
Doe Receipt k
Will the applicant or future building occupant smm or handle haeardous material
as defined by the Cupertino Municipal Cads, Chapter 9. Lt. and the Health and Safety
SEATING UNIT (OVER 100,000 BTU)
TOTAL:
Calc, Section 25572(v)1
❑ yes ❑ No
VENTILATION FAN (SINGLE RISID)
ISSUANCE DATE
A i
BOILER - COMP (31 LP OR Im,Ig10 BTU)
Will the eContammrfmure defined
hazardous air cnmuminams n defned by the Bay Area Air Quality Management
by the Ba cequipmem ualityc Management
Dlstdo7 BOILER- COMP (OVER 100,17(10 BTU)
❑ Yes ❑ No
I have read the hmnrdum materials mc.immnts walk, Chapter 6.95 of the
NEW RESIDENTIAL. MHCH. SQ. FL.
NOV 17 1994
Cxlifnmia lleulth & Safety CWe, Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a tenant. Lou, it is my responsibility to notify the
nwupnm of the mnt
yuimcnn which most he mel prior to Issuance of n Cenl cafe f
CITY Ur v INU
oe cy. 7e
ISSIIEDIJ .
ownroruuthoriudagem Date f
OFFICE