27373 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO °2G-FTS PERMIT NO.
APPLICATION/PERMIT PLUMB INf. MRCHANICAI, 7
BUILDING DIVISION BUILDING PRIIJECI'IDENTIFICATION I
BUII.DIN�A� �� �� � SANITARY NO. /APPLICATION SUBMITTAL DATE
OW -',NAME.. ',.F�F.: O�ACfO 'S NAM' L�ONO: ^_
rG/i`� , VL NlC CONTROLIg
•ANCt 'NGTER: LIC NO IRESS: ❑
CONTACT': PHONE: c.t�a BUILDING PERMIT
QTY. ELECTRIC PERMIT �J lrt1a�O
BLD INFO
MF
PERMIT ISSUANCE ELECT UMB
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OCZ I hereby affwghat l am licensed underprovisions ofaVocre)mommermingwith
P302 Section]OW)of Division 3o1'the Businessand Profusion Code,and no,license is in Pp
FUL,� full farce and effect.I2 \ ►
License Class�yqy�—+�a�-��.Lica:DG� UPT0200AMPS `
FyZ Date - ARL'HITF.CTStDECLARATION 201-1000 AMPS SQ.PIT.FLOOR AREA $/SQ.FT.
ZOy_— IunJemund may,plandsRshalllbe medus public records. OVER IOOO AMPS
SIGNS ELECTRICAL
'ccns"it pr dessionnl \, O
K hat I am BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
W 1 hereby affirm that I.m exempt from the Contractor's License Lew for the
tKil3 a y which regmason(Seaton co3L5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
FuQ; which requires to construct, demolish,or repair any awnurc
W,}� prior to its issuance,also reclaims the applicant for such permit w file asigned statement POWER DEVICES
C L4 Q hat he is licenmd pursuant to the Provisions of the Courtesies License Law(Chapter
VALUATION
iia. 9(c.mmencing with Section7")of Division 3 of the Business and Profaesi.ns Code) MMING LELECfItIC AL 111
=y .,that he is exempt therefrom and the bssisfor the alleged exemption.Any violation of
its
FZQ Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty.( UThETS-S HES-FlXTURES �+
E=D not more than five hundred dollars($500. NEWRESI ALELECTR _SQ.FT. STORIES TYPECONSTRUCTION
WF22 ❑ lasothe w work,
an the
orm regoasthei(sole compensation,
1'T. and Pitbcwork,and the nmctareisnot r's Lieedorawdoforede(Sec.9o96. wniros
and Profusions Cade:The Contractor's and
oes Jon not apply lf an owner is
property.r wyxr,,d,vidxd mvo Itcrc m,end who Jncs Hoch work M1ims.lfonhrough his
' cnspinyeca,pmviJeJ that such' pnsvements urcnut intended orofkmJ fur s�le.IL OCC GROUP RES.UNI'T'S
however,the building prnvemc "sold within one yearofcompletion,theowner-
builder will bu uden of pmvin that he did not build or improve for purpose of r—
aide' QTY. LU BIt P RMI FEE MOOD ZONE APN
❑ I.asownerofthep n , exclu.'velyconwctingwithlicens cont, wmto
n wet the proj ( 9 and Professions Care)The Contracwra
tic noel d owner.( nywM10 builds w improxathereon,and PERMRISSUA
wh c r. To so'cengwitha tracwr(s)li<rnsM pursuanu.the Conv.cmfs ALTER-DRAIN&VF WATER(EA) FEE SUMMARY
Lic nm 1
❑ I em To under .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTsIDE ii FS
SANITARY YN
Own c Dam DRAINS-FLOOR.ROOF, GOND. RECEIPTp
WORKMAN COMPENSATION DECLARATIONSCHOOLTAX Y_N
xIu,nehyeifine that l have.cedifia:meof conch In self-insure,or is cenilicam of pIXTURES-PER j!tpA�A
"",kers'Compensation insurance or a ecrified copy thereo[(See.JSW,Lab C.l which PARK IPC Y N
coven all cerNe,i ds under this pewit. 6M'LETSRECI I 0
Policy
BUILAINkDI SIGN IBES
Company GAMEA.EA.SYSTEM-OVER 4(HAT PIANCHECK FE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city impation division. GRFASFIINDUSTRL WASTI3 RCE GRADING FE
CERTIFICATE OF E%EMI"I'ION FROM WORKERS' rX
GREASETRA", SOILS F[E
Al
COMPENSATION INSURANCE '
TJix section need not be completed ifthe permit is forome hundred dollan($lo0 SEWER-$XWFAEY-STORM HA.20KFT. ENERGY i C D
or lev.)
I certify that in the performance ofthe work for which this permit is issued,l shall L WATER HEATER W/VCNT/ELEM
no,employ any person in any manner as to become subject to the Worker' PAID
Compcnalionlawsof Califomia. Date so WATER SYSTEMaREATING O tp
0 z Applicant
z0 NOMETOAPPLICANT:If,after making this Cenifcamof Exemption.you,hould NEW RESIDENTIAL PLMII. SQ.FT. 1'0'1' ,
I" become sobjcnwthe Worker's Compcnsvhon provisions of Ne Labor Cole.you must
� ; funhwith<omply with such provisions.,this pertnil shall be deemed revoked. BUILDIN
1 Q CONSTRUCTION LENDING AGENCY SEISM ..
0 2 Ihembyaffirn that then is.construction leading agency for The performance oflip
C) 0 the work for which Nis permit is issued(Sao 3ov9,Civ.CJ f: RI FEE
Lender's Name �—
F Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING
0 V 1 r.nify that I have road this application and stare that the above infomtarioo is MECHANICAL
correct.l agree w comply with all city and county ordinances and stare laws relating w PERMIT ISSUANCE
F UO building constructions,and hereby adh.rize representatives of this city mem,upon the CONSTRUCfIONT X
U 4 .bove-mcntionsi property for inspection pdposes, ALTER OR ADD TO MF.CR.
(We) W t ,indemnify and keep Fawkes the City of Capering,against
IiandLiarqudgmcn ewrsando 'wM1icM1 may In any way twerucagainst said City AIR HANDLING UNIT(9'O 10.000 CFM)
nscyurnc rM1e Rr t' This pe ti
. S AIR HANDLING UNIT(OVER 10,(100 CFM)
igndure of pplicwon Data
�7 EXHAUST HOOD(W/DUCT) PAID
HAZARDOUSMATERIALSDISCLOSURF. TL HEATING UNIT(TO I100.000 BTU) Date Xeceig,p
Will the applicant or future building accepting store or handle haverdous materialA .
as JCGned by the Cupertino Municipal Code.Chapter 9.12,and fire Heahh and Safety HEATING UNIT(OVER 100,000 BTU)
Csdc,Section 25532(./? VENTILATION FAN(SINGLE REST DI
❑Yes ❑No
ISSURNCEDATE
Wdlthc upplir mor future buildingoccurymuuecyuipmenrordevices which emit BOILER-COMP(JHPOR IW,IXN)B'IV) P N
A
/ 'e t
nna air conami 'm,as JefA.ned by the Bay AAir Quaan
Groggily Magement BOILER-COMP(OVER 100,000 B'TO)na
Lin'! ppf°� Qo
_
11 Yes ❑No NEW RESIDENTIAL MI?CII. SQ,FT. MAR 28 1995
I have mad the hazadous malcriula re meemeds under Chapter 6.95 of the
California Boulth&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a naresponsibility dify
m.that it i.my reonsibility to ethe Ice Uh
mGUrtHI�(`
sccupamt of the"oimm on which must 4 mel prio,to issuance of a C."ifecte of t/
Occupancy.
Owner or authorized agent Dae TA ISSUED BY:
OFFICE