27930 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDI -EL CTRICAL PERMIT NO.
OFC DIVISION APPLICATION/PERMIT INGRO
PLUMBING-MECHANICAL 27930
BUILDPROJECT'IDENTIFICATION
BUIIDING ADDRESS: GILD//�� D SANITARY NO. APPLICA ONSUBMITTALDATE
� Gr 1 UNIT# LOTH � 7,
O eR NAME: _ ONE: O RACfOR'S NAME: IC NO: N/C CONTROL#
•ARC CUENGINEER: LI O: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
(y 1 `1 i/� QTY. ELECTRIC PERMIT FET,
I 1� yV N A PERMIT ISSUANCE BLDG E PLUMB MECH
❑ 1:1
❑
LICENSED CONTRACTOR'S DECLARA ON ^ ppp1.IANCES-RESIDENTIAL IOB DES IPTION
000 Thereby ofrmthatl 3 ofthnsedunss ndPeiansions Codr and mmeneingnse with
ta100 no mo7000)of Division3 of the Business and Professions Code,and my license is in ppryEl,S /��
,UE fulit end off /ir C
lQ.,2m License Lic.#_y� UP T0200 AMPS !.r ..a
ce Q ti Date
Contractor �— 20I-1000 AMPS
Fyn ARCHITECPSDECLARNHON
SQ.FT.FLOG AREA $/SQ.FT.
2 O y OVER 10110 AMPS
1 understand my plans shall be used as public records.
�.y. ; SIGNS ELECTRICAL
p. - Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X 0,w 1 hereby affirm Nat 1 nm exempt from the Connector's License Law for the
W}i 0.m following reason.(Section 703 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
P, which requires a permit to cnnswcq al2t improve,demolish,or report,any swcmre
w}� prior to its issuance,almonplres the applicant for such permitto filen signedstatement POWER DEVICES
that he is licensed pursuant to the provisions of the Connector's License Law(Chapter
9(wmmamem,with Section 7000).[Divinion Softhe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
pl--y or that he is exempt herefrom and the basis for alleged exemption.Any violation of OUTLEfs-SWITCHES-FI%TURES
Section 7031 5b any upplicant for a permit subjects the applicant to a civil penalty of
log set more than five hundred dollars($50(h). NEW RESIDENTIAL ELECFR 5 .FT.
[I I.mawnerofthepropmy,ormyemployeeswithwagesastheirsolecompensation, Q STORIES TYPE CONSTRUCTION
a will Bothe work,and the suucturels not intendedminfferm forsale(Sce.70afTBusiness
and Professions Code:The Contractors License Lew does not apply in an owner of
property who b u ilds or improves Hereon,and who does such work h imsel f or thicu gh his
.an employees,pr ovitledthatsachimprovemen[s weno[intendedorofferedforsele.if, OCC.GROUP RES.UMTS
however,the building Or improvement is sold within oneyearof completion,the owner- IOTA
builder will have the burden of pmving that he did not build or improve for purpose of
1u).
❑ L as owneroftheproperty,smexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(sec.7094,Business and Professions Code:)no Contractor's
License Law does not applyto son ownerofproperny who builds in improves thereon,and PERMIT ISSUANCE
who contents forsuch projects with a contracmr(s)licensed pursuant to the Commences ALTER EA FEE SUMMARY
LicenseLaw. ( )
❑ 1 am exempt under Sec. B&P C for this reason OUTSIDE FEES
BACKFLOWIPR D SANITARY Y—N
—
Owner Dem DRAINS-FL `Od AREA, RECEIPT#
WORKMA14 COMPENSATION DECLARATION , . SCHOOLTAX Y N
I lumpy affirm that l have.certificate ofcorecm to sel6insure,or a cerlificateof FIXTURES-PER TRAP RECEIPT#
co cover,
al u[son i'ed copy thereof(Sec.3900.Tab C.)which PARK FEE Y N
ars elle i spa rD-7 ..l\J GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
�Co'p{'any M GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
�rCenified copy is hereby fumnshed.
❑ Certified copy is filed wit the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS ME
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is become hundreddollars($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the performance ofthe work for which this Man is issued,l shall WATER HEATER W/VENT/ELECfR
not employ any person in any m as m become subject to the Workers' PAID
Z Compensation Lawson Califomia. Data so WATER'SYSTEMMEATING Dam Receipt#
C) Applicant -
2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL FLATS. SQ.FT. TOTAL:
V) becomesubject to the Worker's Compensation provisions ofthe Labor Code,you must
ai forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thatthem is a construction lending agency for the performance of
U O the work for which this permit is issued(See.3097,Civ.CJ TOTAL: ELECTRIC FEE
w PLenders Name
U Lenders Address QTY. MECHANICAL PERMIT PEE PLUMBING FEE
1 certify that I comply
read this application and county
and state that the stave information is
�^ a
comet. lagree no comply with all city and county ordinances and seta laws relatingmPERMIT ISSUANCE MECHANICAL FEE
Oei building construction,and hereby authorise representutivesofthis city to enterupon Ne CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs andexpenses whichmey in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of ApplicanisCommnor Date EXHAUST HOOD(W/DUCT)
PAID # V
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100.00)BTU) Dam Receipt#
Wadhyll the eC.atorfumreicipal Code,ng paperoremr handle Health us and Safety HEATING UNIT(OVER 10(1001 BTU) TOTAL'
al
as defined by the Cupertino Municipal Cade,Chapter 9.12,and to Health and Safety
Code,Sectio Y�532(n)7 es ❑No VENTILATION FAN(SINGLE RESID)
Will the applicantor[uturebuildingoecupent oseequlpmenwrtlevlceswhiohcmit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
immet?
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.IT. ��� 12 1995
1 have read the hazardous materials requirements under Chapter 6.95 of the r u
California Health&Safety Code,Sections 25 25533 end 25534.1 understand that
if the tinkling does mol curtently have a ten t at it is my responsibi'ty t notify the
occupam of the requirements which most et nor to issuance ertifi ate of 1' Vt vsn L"I'T I IIV�
Occupancy e�
/2
Ownerorauthaizedegent Da TOTAL: ISS B
OFFICE
.TA�BL•ICARFT' �KL[IN�IkHF MAtIHN AIfiNIN NEtl LINER-,USE BALL POINT PEN ONLY PERMIT o. .—�. '
C fi�dF f" I♦�"IFfiIFId PLdMB1Ntl•MECtIANICAL .0 M'/7 9 3 O
MAORI biwAdN
A�6L1CA hi8iv/pi ifl>41 h L 1.V
•r:-eR'drs tl
o. G ueAL DArB
DBMS::r t w1"Nowt,a'�'wd'. .w-,.r. ..:..., -..t. .... .. ... t: p v ,-
D
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� , 1 �UNPT✓fERB NAM
trr 0 ACfOR'S NAME: NOi♦ 0
Vf� 4a,�{
.t /PNOMEER: `:.i: idr�,' O: :S. ADDR' i ❑ ' i
All
NfACf: t PHONE: J y
D 1• �I✓N B� Y�SA PLUMB MECH
. b i ,'' ; PERMIT ISSUANCE .rb:'b `+::iJ s .ir: • - ❑ K-�. ❑ ❑
LICPNSm CdNTRAtrbK 3 bPAiwRA ON I APPLIANC�9=ResIbENTIAL v A `,,' y^t"' OB DPS ! ON
�`ItioeM.m�m1681tiaideA m�riGw♦IdanibrOuP7r19(ooln,w:cini�iJi :` _M i /��p0 SaRan 7EOOJNOIW,b.3 o/dm Bud«.7end Profeolo�tede..ed Ylka:sk� PAiJP1S '.• ' -I � p � ��
full
' ted �"'�0 w�Cv.�♦♦,�,llV/, , .
201-1000 AMPS ra aAu w SQ, ARBA fISQ.Pf.
fF..5a t�t �.•• A C1111T.C1'9b
110N V- S OVER IM AMPS ::. .,•K"c&.. . .w+...+• °'�"1. jf
Z7 Imidenlu�mj•p Well 6e add G p'Ubllefecard,
, A. ♦ SION9 ELECTRICAL •,.i t.-uVl ,y-„,,,.,,,,,...
5yd „ .. OwNERRbILDPRb6ci.WiddN (. ' sPEMALtfRCI)I+YMIsc , 7".F! iTn'
.
.`,f.i wig,
y.R11M di.i I un exempt frau du Contr.cla,i,fccn.e V foi ihb� I - i 3pL rrJ PdlewinJ{tenon(SxBa.7631S Wil”ud Plofealoa Code Any8iymcmmti J 'IBMP ME1 OR POLE WST
e1 y.5 Rich Ftqulta a pmnil m C�In,Vucl dla hnpmva demalbh,&tcpeu ewcma : pOW'ER DEVICES y, la�',`^ v " ♦ .i `,Q'
y pW«into Wuuue dwrtqulm Om.ppli enlfa,mhp mdI nEle. 1 mmumvenl
<p BuI N.Ii Nim d putaun l�O the Vve blain of l6e Co.Wcld,tAcen,e V (Chepiel I SwIMMINO POOL ELECTRIC VA DAnDN
p }
4(eo:mmmnala{with SeWm7000)of bl blonlordk B.dneY ud Prvfwio:ie Cade d , "I` i
f g
e�y bi Rut hebeitnipl lhetefraR ad me boli!«Ik dkyed aempOon Any'IWonoi ( OVDMS.SWITCFIES FOC}UMS
< Seblla'f70Ji3 by,.nj•e(plkunl fa ipemiR,bJecu the eppllanl loe.IWlpaulryd
C m.i 11un0 a hudrtd ddlw(f3ooj. i NEW RESIDENj1AL ELEt1R SQ PP C •rn,. 4.„�.JJJ
.Iuowmo/16epioperly mmyemployw ithb•.8riulhehwkwinpm,ilim, :off '�Ih~^v .dT
6Ndo duwark adlhe.buew:a lilrotl.mvded Lilt dfoi,de(Sec 7BIC.Bu,i«y . W ,�y, to,
.id Profe.dm+Code:The Canlrrtim,(Jame Lilt Eaa id epplY m.n wea of i- .♦+.. -r2,. •i� x '.f.'. '.a >... .
peJieiywlntiuild,aimpovk,thaal,6d
t r hobwaneevdcpi lo0Yww6unpaMvdedliut,«Iilmpov mahodotoin,eadt;Memdl— « .Y-'
I;RyleartWi
rwonplean ieooWr- !diwwithin
..
.� •' ` ^ (.
b:ilda 'iil h.ahtic bu:dci:ufievvini dbikdid
nut li.M«impw
akj' w r• - , FLOOD ZONE APH
- ❑, b5 ownaofthe P^WIY•weiclu.Ivelywnuecunt altA licas�cmu.riai♦m r ,
cantrup Rtepo)eat l3a ]Odd Balimii.,d Pafadoa Cade)The tmtr.ciord PERMIT ISSUANCE "t �
mleppIYbaowumfpropeny 6obudd,'almpafar,mhpio)amal .w,mecmr(.)Ileaiied pureV.mmthiConti.cbri ALTER bkim st Vnn-wAiti(
I ! l❑n 11'p - I.. ,� A P C fa r1,E ieuoii BACK FLO + f - • 'N
t un ac ui:dcr N.� SAN Y i 4 Y. PT.—
Cup
f t'-- r—
.r _ U.VIA'p GRAINS.P7. .A .COHb .yl,! t ]. 3 SCHOOI:TA% .�. Y IPf t'^N
t WOR MPBY79ATI0 b {,� . _
here .ffiwm-it6 e.anlfkeb of b.eif ln,we.«bteAEcim of FIXTURES-PER iiuP ✓ ♦ ,y, A :. :�.. Y _N
Compenullmil raao eaNRuim Y16eteof 3800 LebC) hick V r : y
Ziri.fl e"" iip ,' OAS-EA.SYSTEM-1 INC AbVI{hTs tx4.vS rr•F r..l 1� .BUILDING DIVISION FEES
..w,,.i~'
far„W♦ Pully w V 'v OA9 .i„i.
YCIBC . I,.wY ESYSTEM OVER1(EAt♦ �yy PAC.
Ce1JBid copy b Gert NmI had. {{ ,,qq
❑ Cetdlled mpY 1.Bial•d161h8 elry G,pealdn Blvlda,. I�+ v ORP/.SEAIJDUSTRL WiblfiIIdiP �'PJ'T�)R } n .e ORAbINO PPE '
/�� ,r/ �i }E O�?�dI�MPfI0�I7�fOM WORKERS i7 ” GREASE TRAP N<3 May )w: SOIL�FBR .i `�^ � �' .
Eit i - -♦ tOMPENAA11014 INSUKANCE , 1
.. (��ieclionr�dna 6ecomPlelsdif ilm Pemitlkr«one hm,dmdlPoli:a(iIUO) ., SER'ERiIANItAkY.5YORM DA:2dOPP� 4 .$: fz., 8NPJ6bY PEE :Y
7 61:Iw) `�Iltb ieEotk�ol 6Riu ti,fluSiJ.i,iwl WATER tiPAiPk wrveNP �, �,� � � J� ` [�,�
✓ IFa. i6 l in lPb pvfanlw�i'm"o w wide perm ( PAPD i [i
• bei' uMl y Y♦aY Wioe In omlyw nwmei,a u m itecane abJa,1 dm Wo,ka,' K'ATPJ29YS7fIM/IEBATIIJt'Iy . �4 a.A. .-! -,xt1_ .,.—.
” ..• ttimpcn,ulan VW.ofCTltamli. b.le' , A'd' e1 .
Q '7" A7PIic'"1 , t. , S NBN RESIDPI'fTIAL PLM ^ 'h'V" Sfi lrh "j. �..:-1 i TOTAL:
O NOTICETO APPLIUMP if,fmr me6iy Rd,CeWEe.te of R.emp0a4yau,hould t
t P fn b'iaome mbfM 'o IM1i W«ka,Co,apuii.O Jjjjoaof thetbar Code Julmua _�. 1_ EOILbINtl FEE 'J
' torB:wldl tt"l�♦q 1. Bmh Rrovbloa«SU permll.iwl be dxnd mrdat 'a
SE13AbC FEE
q Ecrghitz-HA 1.16198Abkic`y 1 {
ircrtry.il�i n�QSi Jr eUiiwu'vucUan leiWii�4 %fa the plXamwisor 1 '7r {OTAL :v.{�._...«!.. I FPB
Rre Work fa Whkh m pemdl b luued(SK.3097,pr.C.)
Num 4 .. . PLUMBtNO FEE b
�ceV+j( t outlry Ilut I love Uid W..Fplk.dw Gd wm tlw dmiba i famedm le .., A} MECIIAFBGL FPB
1
-atect Sjreeb -'�Y Id:dl dly ud county odinuvx.ud wb bw.rtlidn8w I PERMIT ISSUANCE �-
6uildlniwmouWhacby..udwla rtpraaudva of Nb Ity uialaupm dW ,
ALTER b '.r, .•
itime tnatlalrcb propmr ra Iluprcilon d Abti?O MEcI l` ,E, A.t . l {
pury«c� COlI3SR
1 F7 / (Wel.pu w it
a e I.d ifyr uid,4ap huo'dau If,i C�tY of Cupertino i{dn.i
CfION TAX pB;
II,bllitla Judpumb,cow.nd apa.a ahlch nut In ay wiY..iip ntudd City AIR I IANDLINO bNIT(TOIBOEO,C*M)ikef!
N bon,egvena of the truiBntbf llJ,p«WL
� L 1 .,-, AIR HANbLINb UNh(bvPk,iR.asb cPAPS itti ;, ,�, .
If71 w T i
1 . ' sifnnua fApplmaVC tr.amt r �• .••�, EkHAD§P 3100D(wtiucl)
1 i Dem
HEATiNd UNIT(To lm,00b ETip .J :dz w i FAh7 D.b Rare—ipi- !b
iUukbddsMA'it'kIA14I.MC1o0S BE xI ,toFA
I Wlllll�m.pplicenl«ftrtb.11dliy oaupint,mte of hudle hairdmi me'lerid HEATING UNIT(OVER IW,E00
o defined by the C."Ifi.Munlclpd Code.Clbi lir 912,W the"math u:d Sdety -
Code,SceiVon23312(117 VENTILA71ONEAN(SINOLERESib) - J-
❑Ya d No e~ - -+r• ISSUANCE DATE
EOUZR-COMP(311P OR 100.00E flTID F
WIO Um'"llc.nl«tion e.lime by
hij I"'1 adeWw Wtijowrl ♦ jl
I,ii.Woiu dr wnliwdnmu d dcBnd by the Bej Ata A4 QwIItY M.negcmen' BOILER-COMP(OVER 10).0)0RtV)
%wkt
�. Ove: ❑No - NE*RESIDENTIAL MecU _ SQ_FT.
APR 12,1995
1 halt mud Rm hvatdm,`•nW♦ahL rtqui'iieimu Dade Chepta 6.93 of Urz j
' C.1 faml.Nalco k Sefery Cade.Sa'llm,23 233]3 ud 23311.I uidmwid and . . '
If the 6oiNinj doge imlamadY
' aocca 'u. ' �- �...} . ,,.: Vf' vl.: CI''1•-1,e1p1V.-V.
11
...w' ip:tluRIr01V1iYf0 � �?PP*'•
1K'!C'>• or mobod ed yea • D. ., '.H
iss B
OFFIC41 a '' .
W.