27206 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ONCUPERTINO
BUIL UI G-ELECTRICAL PERMI'I'NO.
INIhDI fe DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0
BUILDING PROJECT'IDEMfIFICATION
BUILDING ADDRESS: /}/�� /, �//k (1 /y�� SANITARY NO. APPI-CATI�_ON SUBMITTAL DATE
6 I� 100 r"140-�1n UNIT# I /Qr) Q-11 J LO]Ta / / �/ �
O iRS NA E' PH BE CONTRACTOR'S NAME: LIC NO: `r a�
Mme YD ys/40O ocener N/C COM'ROL#
• ARCIITECTi NGINF.1'A: PIC GG ADDRESS:lLXY// ❑
COM'AM: PHONE: BUILDING PERMIT INFO
QTY. IiLECTRIC PERMIT FEC
BLDG
e ceo err` PERMIT ISSUANCE s ELeCD, PLUMB MECIi-
LICP IID CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OD-O� JsrOJ}B`DESCRI LPI07N'
pyz I herebyaffirm that l an licensed underprov onsofChapter9 fcorslmencingwiN
LLdu Sectforceandofect, un3 of Ne Business and Professions Code,and my license is in PANELS sFDF�/L
�s�+
fullLicense
nseClas effect. UP TO 200 AMPS
Z,DJ Liaxnu Class Lic.p
o, I Date Ccntractm 201-10(1(I AMPS
Z0 z ARCHITECTS DECLARATION OVER 100)AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z-p I understood my plans shall be used as public recam., 4//0
� ,^
r ti�oq SIGNS ELECTRICAL 4/,V
g�qq ...4I Licensed Professional
L Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /..(f/�
F1 hereby affirm that 1 am exempt from the Communes License Law for the 3 9 •y T
ts+3 tr-m following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
EJ C which requires a permit to construct.alter,improve,demolish,or repair any structure
a� prior to its issuance,also requires the applicant fersuchpermiuofile asigned summent POWER DEVICES
W <pC that he is licensed Futuna to provisions ofthe Connectora License Law(Chapter
aax eLL 90,mmmencing with Section 700mof Divisimn 3ofthe Businessand Professions Code) SWIMMING POOL ELECTRIC - VALUATION
W_rn
or that h7031.5 npuhemfromard the basisfar
subjects thedexempti h Anyl psmaon of OUTLETS
Z a Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of b
yy not mom than Eve hundred dollars($5110). 11
dFo ❑ 1,asownerofJre yemp y g pensmion. NEW RESIDENTIAL LLECIR _SQ.FT.
propcngmm Ire .d.r offered
seesalei(See coat STORK TYPE CONSTRUCTION
will Ju'be wmk,mode: aernme Cmdrano,immmMdm Law
osact apply
to sm owner
of
andpro Professions Code:The Contractors License ow does mar apply R h owner is
property who builds or impraves Nereom sad who does such work himself sir through his
own employees,providcdthatauch improvementsarenorimmndedoroffered(orule.If, I OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearn(completion.the owner. 7Ll
bander will have the burdenaf n that he did not build or improve for TOTAL:
provi g pro purpose of
ale.).
❑ I,mownttnfNe pmpmy,ameaclusively convening wiN licensrd contracture to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Carlo)The Contractors
License Lawdoesnot apply toanownsrofpmpeny whobuildforimprovesthnean,and PERMIT ISSUANCE
whormennu for such projects with m comorefor(s)licensed ptrsuannodu Cnauacter'x
License Law. PAALTER ( ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for Nis reason BACK FLOW PROTECT.DEVICE O TS DF.FF. S
SANITARY YN
Owner Dam DRAINS-PhOORROOF, CONI. RECEIPT
, , ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Thereby affirm lhm lhaveeceni9cum of conunuoself-insure,rracectificme of RECEIPT#
FIXTURES-PER TRAP
Workers'411e ploy"ianler flux
thertof(Sec.lA00,InbCJwhich PARK IL9 Y N
ars all employee's under Nis permit' GAS-LA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION EELS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cendred copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This sechnnneed nutbecampleted Tfdo,permit is feature hundred Jullws 1$100) SEWER-SANITARY-STORM LA.2(1 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Person wry m as m become subject to the Workers' PAID
z CmnKm.inn Lawseaf C#lifomia. Date so WATER SYSTEW REATING Data Receipt
Applicant
C) 2 NOTICE TO APPLICANT:IL sifter making this Certificate of Exemption,you should NEW REST DENTIAL PLMIL SQ.IT. TOTAL:
rU] become subject to the Wnhcrs Compensation provisions of the Labor Code.you must G
ha-1 ; forthwith comply with such pnevisionsor this permit shall be demi revoked. BUILDING FEE log-6 ,
W []
CONSTRUCTION LENDING AGENCY SEISMIC FRE O
z I hereby affirm that hem is a construclion lending agency for the perfomame of
U O the work for which this permit is issued(Sec.3007,Civ.C.) TOTAL: ���## ELECTRIC FEL 70#
Leader's Name
0 ^F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE / 70. 0S
U 1 rectify that I have read su
this application and m that Ne above information is
Ida correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEL -710. Os—
€"•a � building construction,and hereby authnriaempreacmtives ofthis city to enter upon the CONSTRUCTION TAX `�6 S/p
U abuve-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
r (We)agrce to save,indemnify and keep harmless the City of Cupertino against M.F cgs
-I costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CPM) • # r�
lure
n conuque celiac 6mat, of Nisperma
`LG 3�.z9�9s' AIR HANDLING UNIT(OVER 10,00(iM sere of Applir.VCnntrucmr�� EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATINGUNIT(TO IW,000BTU) Oa¢ Receipt
Will the applicant or furore building occupant amrc or handle hazardous material HEATING UNIT(OVER 100000 BTG) TOTAL:
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety , �/(�$�tJ
11 Yes 11 No Cede,Section 25532(a)? IISVF FAN(SINGLE RESIO)
ISSUANCE DATE -
Will Neupplicanturfmurebuildin6uccupaatnseequipmentordeekeswhicher it BOILER-COMPUWPOR IOO,00 BTU)
hazardous air mnuminanrs as defined by the Bay Arca Air Quality Management u-
BOILER-COMP(OVER 100.001)BTU)
Dome,)
11 Y. 11Q
YNo NEW RESIDENTIAL MLCH. SQ.FT. JW
MAR 2 9 1995
1 have read the hezeNous materials requirements under Chapter 6.95 of the
California I health&Safety Code,Sections 25505,25533 and 25534. I understand that
f the building dros not currently have a tenant,that it is my responsibility m notify NClnI Y e V1 Ur 1 1IIVu
reconsider of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner m marmimul agent Date TOTAL: 1 701 ISSUED BY:
OFFICE