27115 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R E PERMIT NO.
APPLICATIONIPERMIT PLUMRINC-MF.CIIARICAI. 27115
RUILUINC 131VISION BUILDING PROJECTIDENTIFICAT'lON
BUILDING ADDRESS: �J� SANITARY NO. APPLICATION SUBsonTALL DATI
�Y60�,=V0611
�O � V/�IINITa LOT It Qty
_ PHONE,: CONTRACTOR'S NAMIi LIC NO: L L 1
i'1r�� !' Oi- / N/C CONTR La
'CUFECUENGINEER: LIC NO: AD REJ� f� �N� � w 49 ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT /Y FEE BUILDING PERMIT INFO
B ELEQ' PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby ffirmthat l am licensed under p gwith JOB DESCRIPTION
p0Z ya palPrifesionsCok.maommencin
a�F fulltfarce entJe(e vision 3ofthc business sand Professions Coda and my llcaou is in pgryE15
Zu1 C uClas Gam? LI[.a 3589/ UP TO 200 AMPS �Y
F<aa. etc Cnntractur�6�/d� 201-IOW AMPS pot)
ZO,`"isz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOORAREA S/SQ.FT.
O Z—pp 1 undcnwnrt my plans shell he used as public mcords. ,IS
F yr l_-u1 SIGNS ELECTRICAL
QyF,j Licensed Professional
1',xQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
4x'OaF 1 brachy Nam em
hy am al I exempt from me Contrumoh License Lov for the
tat a O w following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�_.�� which requiresapcmtiuo conswct,alter,improve,demolish,or repair any structure
F. Y� 'dorm its issuancs.also ratio's the applicant for such pemJuo file a signed statement POWER DEVICES
that he is licensed pursuant o the Provisions ofthe Comment's License Law(Carrier
dxao�' 9(commencing with Section VUW)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
W_y or that he iseaemptherefrom anit Ne haisfar Nealleged exemption.Anyvioladonof
l•Za Section 703 IS by any applicant for a permit subjects the applicant,a civil penalty of UTLETS-SWITCHES-FIXTURES
not more than five hundred dollen($SW). NEW RESIDENTIAL ELECTR _SQ.FT.
C F_o ❑ Laowmerof shepmpcny,ormyememaledwithwagmasme(Set.compensation, STOREY:. TYPE CONS'OtUCI'ION
will Jnthewons and(its he Can isnm intendedo La.elves
not
apply t an Business
and Professions Code:The Canal, nd who Lew Jots not apply to an owner of
propemywyees,provi improvesthereon,end ants a ootid work bimselformrough his
own empltyees,p building
ed or
vemech npis sold msarcove earolf dorplemosd pasture. r- OCC GROUP RFS.UNITS
however,the building or improvement is sold within one year or comm a for the owner- ,A
builder will have the burden of Proving that be did not build or improve for purpose of
ale.).
❑ Lathe profNcpee.7(u mnendusivelycorofessions C lim))lac Controorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE, qPN
construcicenset the msnot pply rarronrofBusiness and Professions Code:j The Conion,ans
Licenulawdocr such
opplymawithasmmacluery whosed I..oflmprovcs thereon,and PERMIT ISSUANCE J
wm sc Ls ufm suchprojects withecontractor(s)licensed pursoamn b nnoacmr's
Li I Law. ACIF.R-DRAIN&VENT-WATER(GA) FEE SUMMARY
❑ I am exempt under See. &Is C for t 's season BACK FLOW PROTECT.DEVICE OVISIDE FEES
SANITARY YN_
Owner Data
DRAINS-FLOOR,ROOF.AREA,COND. RECEInt,
WORKMAN COMPENSATE ECLARATION SCHOOLTAX YN
❑ Thereby affirm that l have a cerificat nsem to self-insure,or a certificate f FIXTURES-PERTRAP RECEIPT#
Workers Compensation Insurance inified copy themed(Sec.3803,lab C.j whit PARK FEE Y N_
covers all employee's un
ncle spcnit. RIC FTa
IONCompany clay p GAS INC.INC.40UTLETS B D1 D
FES
GAS-EA.SYSTEM-OVER (CA)❑ Cenified copy s bcreby with
the
h M1 city
(' PLANCHECK P
❑ CertitieJ cop is fled wire Neciry inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING �a
CE TIFTCATEOFFXEMPTION FROM ORKE GREASE'I'RAP SOILS
COMPENSATION INSURAN
!This section ecJ nm becompleled if Ne permit isfm Ilars($IW) SEWER-SANITARY-STORM HA.200 ENERG
or less)
lessifytM1mi theperfonnaaceaft ink f .permit is isamed.ly4li WATER I IFATER W/VENT/ELECTR
not employ any x, n in any manner as t c I'Nal to the W I PAID
Comparted m Ixws Catifacrou Date TER SYSTEM(TREATING
Z Ate
Applicant
z C) NOTICE TO APPLIC :IL after making i edifcia Satptiogyou should NE RESIDENT'IALPLMIL SQ.FT. TOTAL:
Fy become subject to Ne rker's Compensatio ami o ate! Ichor Code,you mu
PoMwim comply with au hprovisionsor Nis uIdo,lbedeed, revoked.
� �_ BUILDING Fh;F.
y Q CO TRUCTIONLENDINGAGENCY SEISMIC
z 1 hereby affirm Nm N in is a construction lending agency for me pc ante of
U O thcworkfw.1uvhthispe disissued(Sec.3W),Civ.C) EL C
U. lender's Name
Ularder's Address N QTY. MECHANICAL PERMIT FEE Pl, FI
I cenily that 1 have read th lication and. the above information is
conics.lagree mcomply widiall city coumy ordinance and nate laws relaing to PERMIT ISSUANCE _. MECHANIC ,FEE
y building amsmuctlon,and hetbytohoriae rcpmsenutives of this city to mte .,the
U Z abuse-mentioned progeny for inspection purposes. ALTER OR ADD TO MECP. CONSTRU ON TAX
(We)agree to save,indemnify and kesp h;omflan e City of Cupertino agin
ast
Indalitiw.mdgmenn,cnsts expermewhic s any way acemeagaimst said City AIR I IANDLING UNIT CrO 10.000 CFM)
in co quince of anting of Nis ry n
/ /a •� AIR HANDLING UNIT(OVER IgBW CPM) I
Signamm of AppbcanVConmacmr Da EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 103,000 BTU) D. a Raeipt p
Will the the Cupertino
m forum building occupant store or handle hazardous material
Cde,SeJhytM Cuperina Municipal Code,Chapter 9.12.and me Health and Safety HGTING UNIT(OVER IW.000 BTU) T
Code,Section 25512(x)?
❑Yes 0 N VENTILATION FAN(SINGLERF:SIU) `
Will heapPlicamorfuture buildiagoccupam useryuipment ordevices which emit L BOILER-COMPLIHPOR 100.00OBTID SF CE DATE
raMous air conmmumull as defined by the Bay Area Air Quality Management BOILER 103,IXIp BTU)
as, 51994
❑Yes EI No NEW RESIDENTIAL MECI I. SQ,PT. M� 2
I have rend the haandous materials requinamems under Chapter 6.95 of the ® e Illvu
Califomia Ifeahh&Safety Corte,Sections 25505,25533 and 25534. 1 understand mat v�GTI
flhe building does not currently have a meant,that it is my reapansibility to notify the G1 Ur v
occupant ofthe requirements which must be met prior m iauance of a Certificate of
occupancy.
Owner or amount)agent Date T ,. ` ISSUED H�
OFFICE