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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO R IL IITITrvU . nLLECTR CAL
APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING DIVISION IIUILDING PROJECT IDENTIFICAI'10N
PERMIT NO.
27360
BUILDING ADDRESS: T �%(.��(�f�-- Xr �s-D
O -Z-C) I • O r I Q— • 1 • c UNIT# L+-`^ r LOTN
SANITARY NO.
APPLICATION SUBB�MITEAAAL� DATE
J
Oy' 1 A5CCD�S NAME [� _ PHOCF-, A 4o
\r
CON' CI'071'S NAMIi: w' I 5 u S� {. CJJO. O
Fw Sn(ST
NIC
El
CONiT—ROL N`
AR II IIVINFP.R: LIC NOL.'^ �I'I_
{•l• fes~/•+
ADDRES �J/�C-��
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
IA , {;hECI' PLUMB ECh
PERMIT ISSUANCE
/yL]��
C
LICENSE.DCONTRACTOR'SDECLARATION
(herehy affirm that1amliCONTunder OIVS ECLAhapmr9 (commencing with
APPLIANCES -RtSIDf:N'f IAL
TOB DFSC�P7 F top
of Divisi 3 of the Business and Proa•f�essions Cole, and my license is in
PANELS
TL:L
fall . and
fall eand effect X
hianx CI ss Lia X /�� ,`.�,
Date — CC7SD a-
A CIIITECTS DECLARATION
I understood my plan shell be used as public ucarts.
UP TO 200 AMPS
` `
rr <r
1
-11I(MAMS
OV201
OVER 111(X1 AMPS
SQ. FT. BOOR AREA
J;/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -exempt Rnflic
SPECIAL CIRCUIT/MISC.
CRATION
1 hereby affirm that I am exempt from the Gonion is Law for the
TEMP. METER OR POLE (NST.
following reresape(Second 7031.5, Business wine
Ca de: Any cin
which alter. improve. sometuty
oi rM1 requires a permit construct idler, improve, demolish, or repair any structure
priorfile a statement
its issused
pat
POWER DEVICES
he ismsorequtheprvisionsofmsuMpemtiuo
that be is ncing w pursuant to the) of provisions nl the Co Business License Lvw (Chapter
License La
9(commencing with Section 7") of Division3af the Business and Professions Code)
or that he is exempttherefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
SWIMMING POO(, ELECTRIC
VALUATION��
"'1r�
UTLETS- SWITCHES - FIXTURES
not mote than five hundred dollars ($500)..
❑ I,asuwneroDheproperty,ormyemployeeswithwagcsan Neirsolecompensadnn,STORIES
TYPE CONSTRUCTION
RESIDFNTIALELECIR—SQ,F'L
will do the work.andthe structure isnot intended oroffeud formle(Sec. 70dt, Business
and Professions Code: The Comtunor's License Low does not apply to an owner of
property whobuilds orimproveathermn, and of odaesauch workhoormlforthrough his
own amp ovidcJ improvements are not intended m onffered formle.IL
rtn
OCC. GROUP
RET. UNITS
AI
It the bat tis sold within ort<yearofcomplmion, thmwncr-
builder w II hove the baM<n of proving t not build or improve fm u
ba.,, Joh
QTY. PLUMBING PERMIT FEE
sale.).
ElLas wnerafhepmpeny,amexclusivelycon,ractingwi,hlicenmdcontnctorst
FLOOD LONE.
APN
instruct t c project (Sec. II44, Business and Professions Code:) Te Conduct. s
License La. dcesnot apply noun ownerofpropeny whobuildsorimprovee thereon, d
pCRM19' ISSUANCE
whocontracsforsuch pnoiecu with acontructur(s) licensed pursuant to the Contract r'e
Lictmve La
pLTfiR -DRAIN&VENT - WATER (EA)
FF,E SUMMARY
❑ I am a rept under Sec. , B & P C for this'rc on
BACK (LOW PROTECT. DEVICE
OUTSIDE FE
SANITARY YN
RECEIPTp
Owner
Data
DRAINS - FLOOR, ROOF AREA, GOND.
WORKMAN COMPEN TION •CL TION
SCHOOLTAX YN
❑ Ihereb
Wnrka%Cn
affirm tbatlhaveacenifi<e • t(mve mse = ,or a cemiffilam f
pensedon lnsurenw oro cc t e, g10tL Leb CJwhi
RECEIPT#
FIXTURES - PER TRAP
PARK FEE YN
GAS -EA. SYSTEM -1 INC.40 S
coves-
covers
overs dL
licy
's under this peony
RECEIPT X
BUILDING DIVISION FEES
Company
OAS - CA. SYSTEM-OVFA4 :A)/
PLANCHECK FEF; O
❑ Certis hereby furnished.
GREASI�INUUSTRLW RCEPPO
! DING ME
❑ Cen, is filed with the city i tion division.
TIFICATE OF EXEMPT ION FROMWORKCRS'
GREASE P
SOI FEE
COMPENSATION INSURANCE(Thneed
SEWER -S NIT Y -ST RM
ENE YFEEor
not be completed ifthe permit is for one hundred dollars(E
less.)Icantheperfortnanceoftheworkforwhich
WATER HEA W/V
n is issued, i shall
not emplerson in any manner so me subject lu the Workers
PAID
WATL'RS
Compenss of Culifomie.
Dem Receipt#
ApplicanNOTICEANT:
IL after making this Certificate of Exemption, you should
NF.W SIDENT1AL PLINQ. V SQ. FT.
TOTAL:
n
become subject to the Worker's Compensation ptov s ons of the Labor Code, you must
forthwith comply wi,b such provisions or this permi, shall be deemedBUILDING
revoked.
HE aiP,
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 herehy affum the, there is a comvuctioa lending agency far the p<if... of
the work for which this permit is issued(Sol. 3197, Civ. C.)
TOTAL:
ELECTRIC FEE
tender's Name
Lenders Address
QTY. MECHANICALPERMIT FEE
PLUMBING FEE
I rectify Nat 1 have read this application and stare that the above information is
cormu. l agree to comply with all city and county ordinances and scam laws mining to
PERMIT ISSUANCE.
MECI IANICAL FEE �-
building construction, and hereby authorize representatives of this city to ema upon the
above-mentioned property for inspection purposes.
ALTERORADDTOMECH.
CONSTRUC11ON TAX
(We) agree m save, indemnify and keep harmless the City of _,no., against
liabilities,judgments,costs and expenses which may in any way accrue against mid City
AIR HANDLING UNIT (TO 10,(010 CFM)
inSnrvxqucncctl tha grunli fchiap�rm�t.
/-N^ A IJ a Na-N{.—G.�
d 7
AIR HANDLING UNIT (OVER IROfM, CPM)
Signature off Appl`icaam//Contmctor�-e:a:ea Yom`
O/ata
12XHAUST HOOD(W/DUCI)
PAID
[EATING UNIT (10 100,1100 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Data Receipt Is
HEATING UNIT (OVER 1100,W(IBTU)
TOTAL,
Will the applicant or future building occupant stme or handle hazardous material
defined by the COpc�ito Municipal Code: Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLE RESID)
Rip
Cade, Section 532(.M.
Cl Yea JNn
BOILT:R - COMP (3HP OR 100,000BN)
1 12fi5 DATE
s�
Will theapplicant orfuturcbuddingoccupere useequipmentnrdevices whichemit
BOILER- COW (OVER 100.000 BTU)
haeerdous air commormants as defined by the Bay-Ama Air Quality Management
Dtstnct? I .
❑Yee �,No
r e
n
C��. �a79S
NEW RESNTIAL MCCH. SQ. FT.
NC
1 have real the hazardous materials papiremems under Chapter 6.95 of the
OF L(J�.IC
California Health & Safety Cade. Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
Hill //VI
occupant of the moBiremeals which mut be met prim irissuance of a Certificate of
Gccapalhy. /��. 11 Q-1-7�
ISSUED BV:
Owner or thorn. dagem Date
A �
OFFICE