27131 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIBI'murs. I- ..FCTRICA. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27131
IIUILDING PROIRC'T[DEIST IFICAT ION
BUILDING ADDRESS: SANH'ARYNO. APPLICATION SUBMRfALDATE
//// TEE <GCHASE OQ/T/f.UNIT# LOr# D
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
M e. STR E�'T. -rf/F
Co. '!;20'7-r4. NIC NT f"LM
ARCHITECI'YENGINEER' LIC NO: ADDRESS:
O "CzlFOOD Com- COPC/n-dO
CONTACT: KEv/,� L12COy/ PHONE: Yr•�- 4tY " "_' - ' BUILDING PERMIT INFO
zSS3(SS,Ql ' E4ETRICPERMI'P FEE
k .'K'i k'3; BLDG ELECT PLUMB MF,CH
Co. J PERMIT ISSUANCE El
T❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIALJOB DESCRIPTION
ancz Iherchyaffrm that l am licenudunder previsions of Chapter9(cotmnencing with ^—
�OO Seniore mid of Division Sof the Business and Professions Cade,end my license is in PANELS -
C full fora mid effect
F Lacer Class C: 3 Lies 6aC039Z. uP To Zoo AMPS
m y D:nc CammnnrTA Rl'z7 Cu 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS Q.FT.FLOOR AREA $/SQ.IT.
OZ-0 I undcmand my plans shall he used m public records.
P qJ SIGNS ELECTRICAL
QY Licensed l•rofessional esk.
�ad'6
OWNER-BUILDERDEhe Conaeme SPECIALCIRCUIT/MISC Y►�\
XOiv I hereby affirm that I am exempt from the Conmsaorx License law for the
1+134y whichfollowing motor.(Section
toco3L5,Buaite.impr Professions Co de:Mycinarcaunry TEMP.METER OR POLE T.
ftJ�� which reyuirce a pcemim to construct,alter,improve,demolish,or repair any ewnum
K YS that he is
i the provisions
of
Contrrmiuofila coigne)smmmrnt POWER DEVICES
W A O
that he is licensed pursuam m the provisions of the Contractor.License Lew(Chapter
pi W:2000 9t(commencing
xemit therefron om,
mid the Division me alleged exemption.
violation
Cad e) SWIMMING POOL ELECTRIC VALUATION
yl_y entre h7031.5 by
end the hanpermfortheaRegedesemptiva. civil Penalty
of ODILFTS-SWITCHES-
=g¢ Sof mo]OJn by anyapplicantfor$pemtit subjects the oppliconnoacivil penally of FIX'NRPS
Ay=0 1morelhnn Tivehundreddollars yemp. NEW RESIDENTIAL ELECTR $ .
Coo n❑ Lnsownerof tbepropeny,ormyemploy«swilhwagesas lheirsolecumpensetion, Q STORIES TYPECONSTRUCTION
y °.e wdido the work,and the therefore is not intended mothered for sale(Sec.7044,Business
Aid Professions Code:The Contrector's License Law does not apply to m owner of
property who buildsorimpmves Neuron,and whodoessuch work himrdfor lhreughhis OCCGROUP RES.UNITS
own employees,provided that such improvements meront intendedoroffered forsale.If,
however,the building or improvement is sold within one yemof cvmpleuvn,the rivals-
builder
wnn TOTAL:
builder will have the bunlen of proving that he did not build or improve for purpose of
sole), orae? h c
❑ I,u ownerofthepropeny,ameaclusive[ycontrecting with licensed contreconto ( i r'" V PI.UMBINGPERMI7" .. y FEF. FLOODZONH APN
ransomer the project(Sec.701 Business reit Professions Carl The Co
nt
ra
ct
or's
License Law dcesnot applym enownerofpropeny whobuildsorimproves thereon,endPERMIT ISSUANCE
whocommrsfor such projects with amortizations)licensed pursuant to the Contractors
Liu me Law. ALTER (EA)) FEE SUMMARY
❑ 1 amn exempt under Sec. ,B&P C for this meson BACK FLOW PROTECT.DEVICE SANITARY Y OUTSIDE FEESN
Owner Date RECIAPTq
WORKMAN COMPENSATION DECLARATION DRAINS-FI.00R,ROOF.AREA,GOND. SCHOOL FAX Y N
,• c❑c l hereby affirm that l have acente
ificuafto seor
consentlf-insare. a ceedricamof FIXI'UR[S-ERR TRAP RECF.1PTp
Workers'Compensation lnaarenceore certified copy ther38M,f(Sce.38Lab CJ which PARK FI313 Y N
rs all employes.under this permit. RECEIPT g
Policy# NWC Z/OOG3 _ OZ GAS-EA.SYSTEM-I INC.4 OUTLf:TS BUILDING DIVISION FRES
Company 60t.AFw/ hS'_ GAS-PA.SYSTEM OVER4
E] Cenifid copy is hereby fumished.hed. (EA) PLANCITECK PEE
ID'Cenilied copy is fled with the city inspection divisive. GREASF✓INDUSTTR.WASTE INTERCEPT OR GRADING MI.
CERTIFICATEOFEXEMPHON FROM WORKERS' GREASETRAP SOILS FEET
COMPENSATION INSURANCE.
(This uctionmad not be completed ifthe permit is formic hodreddallars(SIM) SEWER-SANITARY-STORM EA.2MFT. ENERGY FEE
or leas.)
I verify hot in the perforrommeofthe work for whichdox permit is issued,l shall WATER HEATER WNEMI'IELFCIE
not employ any person in any matmer so as to become subject to the Workers PAID
Compmemion Lawsof Celifomia. Date WATI7R SYSTF.MnREATING Date Receipt#
O Z Applicant
Z 2 NOTICE TO APPLICANT:If,after making this CeniOcate,of Exemption,you should NEW RESIDI3NT'IAL PLMB. SQ.FT. - TOTAL:
U) bettmiexuhjecuo the Worker's Compensation provisions of the labor Code,you must
> forthwith comply,with such provisions or this permit shall be deemed revoked. BUILDING FEE
(] CONSTRUCTION LENDING AGENCY SEISMIC FEE
U Z I hereby affirm that there is a construction[coding agency for Ne performance of AM?
ELECTRIC FEE
O the work for which this permdt is issued(See.3097.Civ.C)
IeadCs Name L) Lender's Address QTY. MECHANICALPE@MIT , PEE PLUMBING MH
WW I certify that 1 have rend this application and slam that the above information is N q ` " "I -v,
comet. l agree to comply with all city and county ordinances mid sloe lows mining to PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby mummiu representatives ofthis city toemcruprnhe GGN$TRHCTIDN TAX
V Z alwve-mentioned properly for inspection purposes. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and kap hamdas the City of Cupertino against
IiaM1ilities,juJgmenos,col tswAeapenseswhich mayinnayw, are rueagnimtsald City AIR HANDLING UNIT(TO 10,000 CFM)
in con'y/-.ucnce ofthe granding VJ of this permit.
CJ
AIR HANDLING UNIT(OVER[0,(1(10 CFM)
O
Sigirwm of ApplicenUCmntmctor Dem EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0011 BTU) Dam RccciptM
Will the applicant arfmurc building occupant ammar handle hazardous materiel HEATING UNIT(OVER 100.000 BTU) T
ax defined by the Cupertino Municipal Code,Chapter 9.12,sad the Health ant Safety
Code.Section 25532(e)7 VENTILATION FAN RESID) a I n
❑Yea Cl No �G W(
BOILER-COMPCJIIPOR 11X1,000 BTU) ®giSUA bDATE
Will iair contaminants
as building by the Bay Area Air Quality
Management 6 N U 1
hazardous air cnmaminams ax Jefine<I by the Bay Arca Air Quality Management BOILER-LUMP(OVER 100,000BT
Dixlrlcl'I
❑Ycs ❑No NEW RESIDENTIAL MECII. SQ.FT. CI I Y W- (aUl rte 1 I1 I'loo, II
1 have tend the flucSafety
Coal
mations replacements 3 under 34, 1 m eras of the V
Coliforms Health do&Safety Cade,Sections 25505,t it and 25579. 1 undcmand that
uselobuilding drwa'nm currently have a I he m that it ix my responsibility ter nosily the
ocaupam of doe reyuiremenaa which must be met prior,.issuance of a Certificate of
Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY
OFFICE