27845 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUH,0I1var-KL..FRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL IO R C
BUILDING PROJFICTIDENrIFICATION 27845 r o 4 J
BUILDING ADDRESS. I' /� SANITARY NO. APPLICATIONSUBMITTTALDATE
=2,77via- ' UNITp / Q( OTk _ 2, ^�15
OW . SNA E: PH NE: CONTRACI'OR'SNC�a Ccs E l•
LCNO: N/C CON'TROLp
' n o 98
•ARCHITECT :NGINF.ER: LIC N : ADDRESS: ❑
CONTACI': PHONE:
' QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
r 0 -606/ PERMIT ISSUANCE BLDG EIEC PLUMB MECN
LI .NS!nTRACfOR'S ECLARATION APPLIANCES-RESIDENTIAL IL]�f/ JOBDESCRIPTION /pL�JI
p P4Z I hereby affirmthm l am licensed under provisioranfChapter9(commenciagwith
P00 Section 7001 Division Softhe Bismesaand Professions Coda and my license is in PANELS ^
yz fail force eClass effect. / / �/
License Glasse Lick UP T02W AMPS (��
m Qv0.i Date Creditor 201-1000 AMPS
ZOrn� ARCHITECTS DECLARATION OVER IWOAhffS SQ.FT.FLOOR AREA f/SQ.FT.
OZ-0 I andemand my plans shall be used as public records. _
QF SIGNS ELECTRICAL
ww< Licensed Professional OWNER-BUILDER DECfARA9'ION SPECIAL CIRCUIT/MISC. Q-(J
OiF 1 hereby.from Nat 1 oat exempt from the Cmumtor's License law for the
R3 ts-vr followingmoron.
(Section 70]1.5,Business and Professions Code:Any city or money TEMP.METER OR POLE MST.
l-!!3 which reclaims a permit to contact,titer.improve,demolish,or repair any structure 3/ 7
A t91Y$ prior to its issuance.also tcyuires the applicant for such permit to file a signed statement POWER DEVICES
O that he is licensed pursuant to the provisions of the Con tumor's License law(Chapter
0.XOK 9(commencing with Seetion 7000)of Division 3 oftlte Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_rn criticalSectio 7031. byanmpt ercfmmandthe raPerisfor@etsthedexemptioa civiny lPnaltyof OUTLETS-SWITCHES-FIXTURES /qy 603. '
FZSmtion]OJ LS by any applicant fora Permit subjects the applicant mncivil penalty of
ng nm mare than five hundred dollars($500). NEW RESIDENTIAL ELECIR f .FT.
`� ❑ I,esowneroDhepropeny,mmyemployees withwegcssstheirsolecompensuuon, Q STORIES TYPECONSTRUCTION
will du Omwork,and the structere isnot intended coffered forsale(Sce.7044,Business
and Professions Cale:The Committers License Law does not apply to an owner of
primrtywhnbuildsorimpmvestherwn,and whodoss such worshimulforthroughhis .GROUP RES.UNITS
own employees,provided that such improvements arc not intended or offered for role.If,
however,the building.,improvement ismid withiaone yearofcompletam,the.wner- TOTAL: Np
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ Las ownerofthepropeny.amenclusively contracting with licensed corrmmusto QTY. PLUMBING PERMIT FEE ONE APN
onstruct the project(Sec.7044,Business oad Professions Cale:)The Contrecmrs PERMIT ISSUANCE
License Law doesnot applytoanownerofproperty whobuildsorimproveslbereoa,and
who contracts for such projmts with amnnotor(s)licensed purs.anuo the Contractors gLTER-DRAIN&VENT-WATER(PA7
License Law. FEE SUM ARY
❑ I em exempt under Seco B @ P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y E F N
Owner Data RECEIPTp
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCIfOOLTAX YN
❑Workers
Conlan thatlhrance.nificAiri cansemereof See.3900,
Lab C.)which
RECF.IPI'p
FIXTURES-PFR TRAP
covekers'C.mpye,,'snlerthis Insurance.1 iron copy thereof(Sec.38W,Leb C.)which PARK FEE Y N
rs ullempinyee's under Permit. GAS-FA.SYSTEM-1 INC.40I1TLET5 RDV
Policy p BUILDING DIVISION
FEES
Company❑ cenirm copy is hereby famished, GAS-EA.SYSTEM-OVER 4(HA) PLANCHECK FEE
❑ Candied copy is film with the city inspection division. GREASEANDUSTRLWASTEINTERCEPI'OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ORGSETRAP SOILS FEE
COMPENSATION INSURANCE
(TMs aceionnes the completed ifthe permit is for one hundred dolhrs(f100) SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
or Iess)
I verify that in the performance of the work for which this Permit is issued,Iehall WATER HEATER W/VENT/ELECTR
not employ any person in my meaner m m to become subject to the Workers' PAID
Compensation Lawsof California. Dam WATER SYSTEM/IREATTNG Dam p
O Z Applicant
O NOTICE TO APPLICANT:If,after media Nis Cmiflcatcof Exem flim, ..should NEW RESIDENTIAL PLMB. SQ.FT.
8 P Y TOTAL.:
r V) became u
subjeco the Workds Compensation provisions.(Ne labor Code,you must BUILDING FEE
forthwith comply with such provisions or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby affirm that them is a construction lending agency for the performance of
V O the work for which this Permit is issued(See.3097,Civ.C.) TOTAL: r70 ELECTRIC FEE 170 6,9-
Under.
sLenders Name TEF.
0 U Landers Address QTY. M12CIIANICAL PERMIT FEE PLUMBING
I cenify that I have read this application and stem Net the above information is W
W cooed.l agree to comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICALFEF:
tEn building construction.and hereby outhouse tepmuntauvo ofthis city to enter upon the
V movementionm property for inspection purposes. ALTERORADDTOMECH. CONSTRUCT ION TAX
(We)agree m save.indemnify and kccp harmless But City of Cupnino against
liabilities,judgramU,costs andexprnses which may in any wayacetoe against said City AIR HANDLING UNITQO I0,000 CFM)
in aonsryurnce///fff the grmdnpp3 fthis permit. pJ
��� AIR HANDLING UNIT(OVER 10.000 CFM)
Signup of ApplicanVCmdrmtor a Data EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data Receipt p
Will the applicant or future building occupant store or handle hooddous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as definm by the Cupertino Municipal Code,Chapter 9.12,and the Health unit Safety
Code,Smtloa 25532(n)]
11 Yes C3 No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(3HP OR I WBW BTU) ISSIJ,AxE;ATE
Will the acontaminrfu its defined
by the use Areequa Air ualityc Management
IY g� 9
hamNous air contaminants era Jcrned by the tlny Area Air Quality Menegemem BOILGR-COMP(OVER IW,OW RTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. APR 27 1995
I have mad the humorous materials Ismiremeau under Chapter 6.95 of the Ci/l- P
California Health @ Safety Code.Sections 25505,25533 and 25574. 1 understood that Ut. GUf-
if the building docs not corendy have a tenant,that b is my responsibility m amity the
scm,sm of the r Irements which must he met prior m issuance ff Cenfrcate.f
Ocerma; !, ai %�gi28
Owner.Ownero mt� R Date TOTAL: _Jar SSUEDBY:
OF