27607 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO uil' '- I" PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PINGPROJECT ID
IANIFIC 27607_7 6 O
BUILDING PROJECT IUENf11+ICAI'ION G
BUILDING ADDRESS: id- �I SANI'I'ARYNO. APPLICATIONSUBMDTAL ATE
/
t1 �• 'UNITY Q A LOT# �3o ii �1 -,�
O HR NAM.: PHONR:5-6000 Nh IC CONTRACTOR'S NA .: LIC NO: NCONTROLis
i NWE p !�h
•ARCHITECT/ENGIN[ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE,: BUILDING PERMIT INFO
//T / QTY. ELECTRIC PERMIT FEF.
,00
�e Cos p ?,?S`966 PERMIT ISSUANCE HLOG ELECT PLUMB MECU
LICENSE CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL )OB DPSCRIPI'ION �LayNJ�
cxz Thereby affirm that l am licensed underpmvisionsofChapter9(commmcingwith
u10E SrgioetandrfDivision Jof the Business and Professions Code,and my liPANELSeis in PANELS �Q)/
tFy V mu force end effect.
Z I,iccnx Class Lic.p IIP T02tlpAMPS
y=o` Date ac
Contrtor 201-1000 AMPS
ZO an ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $`SQ.FT.
OZ-0 1 understood my plans shall be used as public records.
p 4l-'� SIGNS ELECTRICAL
6Y�,4 Licensed Nutritional
L6=1�4u OWNER.BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOLU1 hereby affirm Nat 1 am exempt from the Convector's License Lew for the
m 3 LL mQ following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
L:i�ar
cJ which requires a permit to commit,elect,improve,demolish,or repair any structure
2""Y1 ;; prior its issuance,also requires Ne applicant forsuch proctor to Ute aligned statement POWER DEVICES
T=K C O Net he is licensed Immunt to Ne provi.kas of the Co tionw oe.License Law(Chapter
❑1 g' 9(commencin with Section 7000 f Division 3ofihe Business and Professions Cade SWIMMING POOL ELECTRIC
Xo gore )n ) VALUATION
m_y
or that 7031.5 by
yaldireand the basis for bjthe
ctsalleged excmption.Any viohtion of OUTLETS-SWITCHES-FIXTURES / !/•�J
Z Q Section]03 LS by nny applicant for a permit subjects rhe applicant..civil pevlty,of
not more than five hundred dollars(5500).
tC � ❑ I,asownerofthepmp y,ormyemploy«swithwagesutheirsolecompertxdon. NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCI'ION
a3— will do the work,and the structure is not intended or offered for stake(Sec.I Buineu
and professions Code:The Connemara License Law does not apply to an owner of
property whubuildsor improves thereon,medwhodoessuchwork himselforthr oughhis
tun employs,prwidW Narsuch improvemm"itionotintendedoroffered Formic.If, I OCC.GROUP RES.UNITS
howcver.the building or iropravemem is sold within one year .of completion,rhe owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of 1704T"'
sale.).
❑ I,as ownerofthe property,am eacluivelyconracting with licensed commeti sto QTY. PLUMBING PERMIT FEE MOODZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lawd«snot apply toenownerofpropeny whobuildsorimprovufficamn,and PERMIT ISSUANCE
whocomme6 forsuch projeco winhaconunetonfs)licensed puvuenttoehe Conteemrs ALTER-DRAIN&V T EA FEE SUMMARY
Lt«nae law. (' )
❑ 1 am exempt under Sec. ,B&P C for chis tensor BACK FLOW PROT ICE O f DL FEES
SANITARY Y_N
Owner Tam RECEIPTX
WORKMAN COMPENSATION oco NS-FL F.AREA,COND.
DECLARATION SCHOOL TA% Y N
❑ Iheeby affirm Natlhave acenificem (conxnna self-imure,ore«rd0care of RECEIPI'Y
Workers employees
nlmuen«rmit, ifid copy thereof(SaJ800,lab CJ which FI R. - RTRAP PARK FEE Y N
covers allcmployee'n under this permit C STEM-I INC.40UTLETS REC
Policy p BUILDING DIVISION FEES
Company GAS-G.S ':M-OVER 4IRA) PLANCHECKFF.E ^�
❑ Certified copy is herby furnished.
❑ Cenified copy is filed with the city inspection division. GREASEeINDU L WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEB
COMPENSATION INSURANCE
Cfhiasecdom modem he complard Rine permit is furnace hundred do11en($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify thin in Ne performen«ofthe work for which this permit is issued,)she] WATER HEATER WNENTIELECTR
not employ any Person in any mamter so as to become subject ear the Work.' PAID
Z COmpenutiou Lawaof Celifomia. Date WATER SYSTF.M/BEVDNG Date Receipt It
Applicant
� Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLIsIB. SQ.M. TOTAL:.
Lt~ U) b omesubjeeuothe Worker's ComWutimproviaionsofthel..bor CW.,yaumuat /
forthwith comply with such Provisions.,his permit shall be deemed revoked. BUILDING PEE
nW. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE S"U'
1 hereby affirm the them is a construction lending agency for the Performance of �-a.�
U Oconstructionhe work for which his permit is issued(SIL.309],Civ.C.) TOTAL: N� ELECTRIC FEE
r LeO• Q S-
0 U Lender's Name PLUMBING FEE 7O• dJ
Lenders Address QTY. MECHANICAL PERMIT FEE
L) I«nify Nat I he.read this application and alae tier the above Inbound.is DSS.
correct, Iagree to comply withall city adcoumy ordinances and state laws miming to PERMIT ISSUANCE MECHANICAL FEE Y
ha' buildin,rournction,and herebytodamee representatives.(thirdly menterupon the �p ^
L) Z above mentioned property for inspection puryaxs. ALTERORADDTOMECH. CONSTRUCDON TAX v 4 OC •
(We)agree us save,indemnify and keep harmless the City of Cupertino against I-.a `/D _�
Iiubili tius,judgmems,costa and expenxe which may in any way accoueagelnat said City AIR HANDLING UNIT(TO 14000 CFM) �'✓/ J
Incn999���ey/enee of1 tnhe,parsing of thin pennit.
✓"" A 1Z .
IIZZ q—let 51 (O
AIRIIANDLING UNITVER 10,050CFM)
Signature of ApplliaanUC rloom T Date EXHAUST HOOD(WIDUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building occupanntorear handle hsaadom material HEATING UNIT LOVER IW.ImO BTU) TOTAL:
as delined by the Cupertino Municip l Cede,Chimer 9.12,end the health and Safetyry
Coda,Section25512001
/1 Y. ❑No VENTILATION PAN(STNGLERESID) SOb X a
❑
WiiltheapPlicantorfumrcbuilding«cupent uxequipmenmrdeviceswhich emit BOILER-COMP(311POR IOO,q)O BTU)
ISSUANCE DATE
• hurallous air«nnamlnams as defined by the Buy Arca Air Quality M....mem BOILER-COMP(OVER 100,0(10 BTU) p
D
DisWct4 B
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A
I have read the hoeardous materials requirements under Chapter 6.95 of the JAN 241995
California I 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
occupant of the requirenems which must be met prior to issuance of a Certificate of
Occupancy. VurtH I IND
Ownerorinamned.gem Date TOTAL: ISSUED BY is
OFFICE