27225APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO IsUs" Umi ...NCTRI
BUILDING C DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL
BUILDING PROJECT' EVEN'OFICA'1'ION
PERMITNO.
n n C
G L J
BUILDINGADDDRESS: -' �.
SANITARY NO.
APPLICATIONSUBMITIAL DNTH
�` /
19 &5& S C B UNIT# LOT
�-C
(1J_CONLT/ROIL^a
OWNERS NAME:PHONE5vON1
EL '`0 T4 GO (G5.'
ACN
•1 LIC NO:
NIC
❑
RCHITECOHNGINEER: IAC NO:
ADDRESS:
214. M61 u ST KOWCO -Cb
:ONT'ACT: PH
qONE:
µA RCA ABJGQBIui �IJ
QTY; art'. °,CLF?,CTRIOPERMIT FEE
BUILDING PERMITINI O
BLDG ELECT PLUMB 1?CII
PERMIT ISSUANCE
6
R
CZ
OpC
LICENSED CONTRACTOR'S DECLARATION
Thereby ofis fea,i Chaptet9nd(commencing e with
mthat Iision con licensed Business
t
Division the Business and Professions Cade, and mylicenee is in
APPLIANCES - RESIDENTIAL
IDB DI'SCRI ION
PANELS
ore add of
rceand cffcet.
int force
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Liceir
Licence Class I.ic.a
Data Conwcmr
11P T0200AMP5
201 - 1000 AMPS
ARCI IITECTS DECLARATION
1 understand on, plans shall be used m public records.
OVER IOOpAMPg
SQ. FT. FLOOR AREA
111
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Prnfessianal
OWNER -BUILDER D ECContra ON
I hereby nffnn that 1 am exempt from the Contmcmr's License Law for the
followin,im....(Section7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, aIle,, improve, demolish, or repair any srmcwre
prison is ismaroc, also requires the applicant for such pmmir to file a signed aartment
that he is licensed pursuant to the provisions of the Contractors License Lew (Chapter
9(commencing with Section 7") of Division 3 of the Business and Profession Code)
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWERDEVICES
SWIMMING POOL ELECTRIC
VALUATION
FZa
C F_o
or basis fonhectsalleged emmptian. Any violation of
Section 7031.5
131.5 mpt by any applicant for
no, ron T03L5by any $500), tsubjects the epplicem mecivil penalty of
not moreownerfive thepro ay,or(5500).
❑ I, asowncrofthepropeny,ormycmployees with wages nstheirsale compensation,
will domework, and the srracumisnot intended oroffened forsnle(Sec. Tf44, Business
` L O�`r
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIALELECIR_SQ. FT.
STORIES
T'YPECONSTRUCPION
and Professions Cal: Tic Contractors License Law does nm apply to an owner of
prnpeny who bui Ids or improves thereon, and who does such work himself or through hie
employees, provided that such improvements we not intcndedoroffemd forsal. If,
OCC GROUP
RPS. UNI"IS
however. the building nr improvement is sold within oneyevafcompietian, the owner
propose will have the burden of proving that be did not build or improve for puose of
,q.*'
QTY;' PLUMBINGPERMIT FET?
sale.).
❑ I.asownerofthepmNny,wnesclucivelycontmctingwiNlicenucomtrxtomto
FLOOD _ZONE
APN
construct the project (See. 7044, Business and Professions Code:) vector's
License Law doesnot apply manownerofproperty whobuildsor impr esthete and
PERMIT ISSUANCE
whocontmcts forsuch projects with acommaorfs) licensed pursuan oche Connac s
License Law.
ALTER - DRAIN & VFW . WATER (EA)
FEE SUMMARY
❑ 1 ttm exempt under Sec. & P C for this reason
BACK FLOW PROTECT. DEVICE
OUTSIDE PEES
SANITARY YN_
RECEIPfa
Owner Date
DRAINS- FLOOR. ROOF, AREA, COND,
WORKMAN COMPENSATION DE .ARATION
❑ Thereby affirm that l baveaceriHorde often tm seIfAT.0o1, oreceniftceR of
Workers'Compcnsation lnsptartce oracenifiedc yrhereof(Sec. 3900, Lab C.) which
SCHOOL'1'AX Y N
RECHIPPa
XTURES-PER TRAP
PARK FEE Y N_
G-F?A.SYSTLMd INC. 40UTL1?I'S
avers all employee's under this permit.
Policyq
REC.'rM
BUILDING D ISION FEES
Company
GAS - •A. SYSTEM -OVER 4 HAI
PLANCHECK FEC
❑ Cenifial copy is here mished.
❑ Cenifiedcap cd with the city in/SURA
GRE,S NDUSTRI. WASTE INTERCEPTOR
GRADING FEE
CE TIFICATE OF EXEM.RS'
GREASE AP
SOILS FI?ECOMPENSATIO(Thisscetionn
EWER -SA TARY-STORM EA. 200Ff.
LNERGY FF,orless.)I
nor becomple¢difehundred dollen (EI
WATT 'f WNENT/ELECfR
crdify that in the pe ceofthespemtit is',lh
ane
not employ any person in myNsoM1 I { th Wo eri
PAID
W/1 R SYSTEM/fR EATING
z
'ma'am1tion lows .1 1.1;1—;.
Reccipta
i U)
NOTICE TO APPLICANT: If, are, At this Cenifcammption, you should
bceomesubjecnothe Workers Compensate nprovisioasnfthel.nM r Code, you most
EW RESIDENTIAL PLMIL SQ. IT.
TOTAL:
forthwith comply with such provision; or Ni it shall be dcanM revoked.
B 1 i PER
A
CONSTRUCTION LEN ING AGENCY
SI?ISMIC PF.E
z
I O
1 hereby affirm thenhcre is a canswa,a. ending agency for the pcdonnance
the work for which this permit is issued (Sec. 3 '!, Civ. CJ
ELECTRIC IE
Lender's Name
LandersAddress
- - -
QTY. `-. MECHANICAL. PERMIT FEE
PLUMHINO E
I certify that I have read this application a nate that the nbovc in ,mouton is
legrwmcotnply with all city and county rdlnances and sutra sruls It to
buildingeonnmedon,andherebyaurhodzereprcmMdvmofthiscie ocateruponthe
above-mentioned property for inspection purposes.
L)
Wwetter.
jrA
z
PERM IT ISSUANCE
ALTER OR ADD TO MECH.
MECHANI LFHE
CONS IONT'AX
i-^
(We) agree to save, indemnify and keep formalism the City of Cupertino against
Iiabilities,judgmems, costs andeapemee which may in any way same against said City
AIR HANDLING UNIT (TO 1QOof CFM)
in consequence office grunting of this permit.
AIR HANDLING UNIT (OVER I0,000 CFM)
Signature of ApplicantlContmctor Data
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 110,000 BTU)
HA7ARDOUS MATERIALS DISCLOSURE
Date Receipt k
Will the applicant or future building occupant store or handle hazardous material
as def red by the Cupeninn Municipal Gale, Chapter 9.12, and the Health and Safely
HEATING UNIT(OVER 100,000 BTU)
'f0
Code. Section 25532(0)1
0Yes WN. J
VF.NTTIATION FAN (SING LE RESID)
Will the upplicmmr future building occupane oseequipmealmdevices whichemit
BOILER-CQMp(3HP OR IOII,IgO BTU)
r.1eNSUfY IdATE
1+ A u
BOILER - COMP (OVER 100,000 BTU)
hamNous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes D/la
DEC�/ 1994
NEW RESIDENTIAL MECH. SQ. FT.
1 have read the Incautious materials remoremems undo Chapter (.95 of the
California Health & Safety Cale. Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have n motor, thm it is my responsibility to nmify rhe
CITY tar wr, Ii
ecnpaat or the requires which must be mei prior to issuance of a Certificate of
O cess
sWfio /p
O i n bona agent ate
T
ISSUED HY: