27853 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .11,11 G-FEEC'TRICA. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n p C
BUILDING PROJECTIDENTIFICATION L OJ
BUILDING ADDRESS: / 'po/�� SANITARY NO. APPLICATIONSUBMIITTTTALDATE
t9e36Q 1/i UNIT Ian C[ 1 LOT /3 „ qf
OW R%NAME: PHONE: CONT CTOR'S NAM LIC NO: NIC CONTROLp {✓
i fat♦'on Hames 9,8"s-M.
tfs=6000alne
ARLIEI ECUHNGINEER: LIC NO: ADDRESS: ❑
CONTACT:: PPRONEE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
4 y a Cod ar d 5 " 7&�.60&v PERMITISSUANCE BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RESIDENTIAL
thin I pyZ I hereby
affirm
amlicunderfofCCermmrneiwiN
J�) /a•.-a d/TJJO�B�
DESCRIPTION
I00Serfform
f Division Jof the Basine,sand Procsions Cidema]my license is in ppryELg
KUUit or it affect.License ClamsNDae
Curnmew, 201 1100 gMpg
ZOy�5ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOORAREA S/SQ.FT.
O Z ❑ I understand my plans shall he used n public records. [(1/
C k SIGNS ELECTRICAL °1 I O -/
C LicemcA Professional
aC OWNER-"empe from the
SPECIAL CIRCUIT/MISC.
c?�yd544F I hereby ..(Se that I am exempt from the Convamor's License low for the 3 9.y
W 3O vQ7 following rcoma Permit
construct,
Business and improve,
dodo li Code:Any city or county TEMP.MBTER OR POLE INST. 7
i y J which requires a permit to constrvct,ehrn improve,Demolish,or repair any awctme POWER DEVICES
prior to its issuance,also requires the applicant for such Permit to file aligned smmment
`J a�'QPermitO thatheislicensedpursuanuoftWovisiomoflhe ConuacweslicmwUw(Cheerer
5
aaP,4 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_, orthft he isexempt therefrom andthe hnisfor me Nleged exemption.Any violmionof
Section 7031.5 by any applicant for aPermit objects the applica
in 8T5-SWITCHES-FlXTIIR[S
act more 1 qy 6 D3-
O In.five hundred do]].
C o ❑ I.mownerofthepropeny,ormyemployees with wegeamtheirmlecompemadon, NEWRIESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,and the structure isnm intended proffered forsae(Sce.II144.Business
and Profession Code:The Commoto ,License Lew dura nm apply to an owner of
property who buildsorimproves thereon,and whodoessuch work himselfurtuoughlik
wnemployees.pmvided that such improrememsmenot imendedorofTared forvle.If, I OCC.GROUP RES.UNITS
however,the huildingor improvement is sold within one year ofcompletion,the owner-
budder will have the burden ofTO
proving that he did not build or improve for pumpou of
ale.).
❑ Les owner oflhepmperty,um exclusio-IycontrnctingwithlicenseJcontrenomw QTY. PLUMBING PERMIT FLOOD ZONE APN
common the pomen IS.,7(1 Business and Prefeeorms Cade:)The Comtrecncfs
Licence low does not apply nc anownersdpropeny who buildsm improvesshinown.and PERMIT ISSUANCE
who contracts forsuch pnrier"with ecomrnetor(s)licensed pursumnothe Commences ALTER FEE SUMMARY
License Lou. (EA)
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDRFMS
SANITARY Y N
Owner Date RECEIPT g
• co WORKMAN COMPENSATION DECLARATION DRAINS.FLOOR,ROOF,AREA,COND. SCHOOLTAK Y N
❑ I herehy affirm that l have a certificate ofconsenuo self-insum,or a certificate of RECEIPT#
FIXTURES-PER TRAP
Woe..11e ployeeionlnswamttoraccrdfiedcppy Nercof(SttJg00,lob CJ which PARK FEE Y N
rs all employees under this permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RDIVISIO
Policy p BUILDING DIVISION
N FEES ^
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE IX�♦�
❑ Certified copy is hereby famished.
❑ Certified copy is Bled with the city inspection division. GREASUINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMMONFROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
(Thin sectilmined nm be completed ifine permit is(erone hundred dollars(3100) SEWER.SANITARY-STORM FA.2WFT. ENERGY Mr.
or leas.)
I certify that in the performance of Ne work forwhich this permit isfunnel.l shall WATER HEATER W/VENT/ELECTR
not employ any person in my manner e as as become subject in the Workers' PAID
z Compensiamilasoid Caffirmia. Date WATER SYSTFIATREATING Date Rtteiptp
Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEWRESIDENDALPLMB. SQ,FT. TOTAL_
F f/1 becomembject w the Workers Compenmdonpmvi,iomofthe Lobo,Code,yau mar
� ; forthwith comply withsuch provision or mi,pennitshall be domed evoked. I BUILDING ME �Q�♦res
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE ♦�
1 hereby affirm that there is a construction lending agency for the performance of
U O the work for which this permit is issued(Se.3097,Civ.C.) TOTAL: ELECTRIC FEE 9 72
I
Lender's Name , PLUMBING FEE 6
F Lender,Address QTY. MECHANICAL PERMIT PEE 7
V I certify Nut 1 have read this application and om-thus the above information I.ti.g is MECHANICAL FEF. ♦ 6 7R
coilifinlagreewcomply wired by ambons cauntyortives asoutside lawsr upon the PERMIT ISSUANCE
U z builJingconsnuction,and hemmrco np purposes.
sof Nis city to enter upon the CONSTRUCHONTAX
U z aM"'Wemioned ropeny(learn ly tion pompous. ALTCR OR ADD TO MECH.
1 Wel ogre o gave,indemnify end keep harmless me City of Cupertino against �55s�s ��I1 A�aerss�
dmdidc,,ju ints,costsan s which may in my way acceugainstsaid City HANDLING UNIT(TO 10,00)CFM) /♦I '�,p{x.�V
in eons ce of theg Ni,spemmit. ryAIR HANDLING UNIT(OVER 10,800 CFM)
aturcofApplicanVContm rt Dew EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE
((EATING UNIT(TO IW,0W BTU) Date Receipt
Will the applicant ininofuture Munbuilding de,Cam store or handle hazardous dSafrmaterial
as defined by the Cupertino Municipal Cede,Chapter 9.12,aM Ne NetlN and Safety HEATING UNIT(OVER N0,000 BTU) f1ryry TOTAL:
Culls.Section 25532(u)1
13 Y-s 13 No VENTILATION FAN(SING.LE RRSID) IC" p �i VV a
❑
ISSUANCE DATE
Will meapplicanerfuwrcbuildingoccupantuuqui
epmenmrdeviceswhichemit BOILER-COMP(311POR 1100,0001311H OCT 9
hazardous air contaminants ints as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100.0110 BTU) 1995
District?
Cl Yee ❑No NEW RESIDENTIAL MEC L SQ.FT. CII Y VY
I have mad the hmardoue materials requirements under Chapter 6.95 of the LVf to I IIT!,
CaliforniaI twit th& cry Code,Sections 25505,25533 and 25534. 1 understand that
if the leadding doe m euremly in, Irnan4 rem it is my respmsibility w notify me
occupant of th airommus ust he met prior to is ocnif
Occupanc /
Owner authorized agent p �Daw TOTAL: ISSUED BY:
OFFICE