27023 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ........ G-I,EEL7111CAPERMITND.
BUILDING DIVISION APPLICATION/PERMIT PI,IIMBIN'G-MECHANICAL 27023 7 O 2 3
BUILDING PROJF,CTIDENTIFICATION G
BUILDING ADDRESS )(� SANITARY NO. APPLICATION SUBMITTAL DATE
I /k�� ! D/. UNIT LOT /0 X71 ^9y
WNERS NAME: PHONE: CO 'RACI'OR'S NAME: LIC NO: NUC CONTROL
os5 S7�000D I 4U
RCHITECf IiNGIN .R: LIC NO: ADDRESIS /P El
/ -'{moi✓
CONTAcr: PHONE: BUILDING PERMIT INPO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE BLDG ELECT' PLUMB MECH
❑ ❑ f�7 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES RESIDENTIAL JOB DESCRIPTION
OClc Iherehywfrmthat l amliceBuinss card Prionaors;Care,and
my[it.g with
�s100 fail
orce and ofect. on3of lbs Business and Pmfessinna Code,and mylianse is in PANELS
FF�Ufull force lass effect.
..Zyt License Class I.ic.# UP T0200AMP5 kal��
yQy Dale Comment 201-1000 AMPS '1
ZCr,z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA b/SQ.FT.
OVER 1000 AMPS
po 1 understand my plans shall ha used as public meoNs.
r Es�nt W SIGNS ELECTRICAL
jgj8— Licensed Profmdnnal
6 OWNIiR.NUILDER DECLARATION SPECIAL CIRCUIT/MISC.
VX 1U 1 hereby affirm that 1 am exempt from the Contactors License Lew for the
pW..Y.a. (,,]]owing reason.(Section 7031.5.Business and Professions Code:Any city ar county TEMP.METER OR POLE MST.
which requires a permit m coawt,site,,improve,demMish,or any m andure
>- , poor wits issuance,also¢quires the applicant for such permit dating downturn POWER DEVICES
40 that he is licensed putstatim thepr�visions of the Comae ra LicenseL (chapter
4 p,oC 9(commencingwitb Secnion]0N)of Divisinn3ofthe in and Pro fess ms Cade) SWIMMING POOL ELECTRIC VALUATION
W_m or he is exempt therefrom and the basis for the all d exemption.Anyv lationof OUTLETS-SWITCHFS FIXTURES
�yQ Section]OILS by any applicant fareawin mM1' utheapplismutateivil Wry of
� C not mom than has hundred dollars 13500). NEW RESIDENTIAL ELELTR 5 ff.W pa ❑ Lmownerofthnpropery,m rat, yxawithwegesuthcirmi.c. tion, Q' STORIES TYPECONSTRUCDON
y3� will do the work,and theswwurc is mendedorefferadforsale(See.]P14,B sioess
and Profession,Cole:The Co mr'a License Law does not apply to an o or of
propenywhabuildsurimpr, stl¢remi,nnd whodassuch work himselfnr cornu his
warmployeee,provid alsuchi-rrnvcmenl, nodin¢nAdoroffe fn wl If. OCC.GROUP RFS. NITS
however,the hail ' urimprovemem is with
rte year cutpl war TOTAL:
builder will the burden of paving that buildmt puryrne f
sale.).
❑ Los. erofthepmpen amu ntrectinI i eased contractors QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the ject(See.] . and Prof tin We I The Contract s PERMIT ISSUANCE
Liecroul.ow Ai . to plyt a w�buildsmireproves the ,and
whacomacterms hpmi t amu keened....sum mm ntremors
License law. ALTER-DRAIN&VENT-WATER(IA) I"HE SUMMARY
❑ 1 an exempt under c. ,B C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y D N
Owner Date RECEIPT#
c DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN CO GNSATIOND LARATION SCHOOL TAX YN
❑ Iberchy off rhatlhnveaceni de of cu Ina sal Ginsurc,orec<nificme of RECEIPT#
Wmken'Cnm msatiet Insurance orate FIXTURES PI?R'I'RAP
pc py thcreof(Sa.3800,LaM1CJ which PARK FEE YN
overs all employee's under this permit. GAS-EA.SYSTEM I INC.4 0UTT.ETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYS'ITM.OVER 4(EA) PLANCHECK HE
❑ Certified copy is hereby furnished.
❑ Curifed copy is filed with the city inspection division. ORHASFgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CPR]IFICATE Oil EXEMPTION FROM WORKERSGREASETRAP SOILS ITE
COMPENSATION INSURANCE
(This sectio adma be completed ifthepenrdt is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or leu.)
I verify that in the perfnrtanamf the work far which thio pemb is issued,IshaR WATER HEATER W/VWVT/ELECTR
not employ any person in any matter so as to become subjee,ad the Worker' PAID
Comparonamnlawonf California. Data WATER SYSIMMiTREATING Date Receipt#
0 z Applicant
Z 0 NOTICE TO APPLICANT:]Lafmr tanking this Canif¢arenf Exemption.you should NEWRESIDENTIALPLMIL SQ.Pf. TOTAL.
p-+ r_ become subjecrto the Workers Compensation provisions ofthe labor Code,you must
l� , forthwith comply with such provisions or this permit shall be dated revalued.. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) HA-11 ELECTRIC FEE
LL, Lender's Name
V PLUMBING FEE
0 Under&Address QTY. MECHANICAL PERMIT FEC
1 certify that I have rad this application and state that the above information is
7" Ila cannot.I apace to comply with all city and county oudianeea and state laws reining to PERMIT ISSUANCE: MECHANICAL FEE
I" Eat) building construction,and hereby authorize repeascnutives ofthis city meter upon the CONSTRUCTION TAX
U z ubme-mentioned property for in, Ino purposes. ALTER OR ADD TO MECH.
(We)agree In,.ve,inderam n keep harmless the City Of Culmina against
li' ities,judg c "ad pe wilt may in any wayacerueagnind said City AIR HANDLING ONI'1'(TO 10,000 CFM)
of th r is, n. AIR HANDLING UNIT(OVER IO,gp CFM)
lJ 1-7 ,
Si Iummf Applican mmavtr ate EXHAUST HOOD(W/DUCO PAID
I IAZARDOUSMA'I'F.RIALSDISCLOSURE HEATING UNIT N 0 100,000 BTU) Dom Recend#
Will the Applicator fnurc building occupant store or handle hseallom mmerild
as defined by the Cupertino Municipal Cd[,Chapter 9.12,and me Health and Safety I MATING UNIT(OVER 100,000 BTU) AWAL.
Cede.Section 25532(x)? VENTILATION FAN(SINGLE RFS ID)
❑Yes ❑No
WIII the npplicanmrfmure hullJing necupan usecyulpmamrdavicee which emit
HOILF.R-COMP(3HP OR 100,0(111 BTU) ISSUANICE D TE
haaurdous lir condominiums as def cd by the Bay Area Air Quality Management BOILER-COMP(OVER• 100,000 BTU) f� pp DistricO P A 9
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT.
1 have read the h uccdons mamritts requirements under Chapter 6.95 of the OCT 31 1994
California health&Safety Code,Sections 25505,25533 and 25534. 1 understand than
if the building Anes not currently have it tenant,that It is my responsibility to nudity the
nccupend of the requirements which must be met prior m Issuance of a Certificate of
Occupancy. ``I'Y
Owmr m incl oriend ageat Date TOTAL: ISSUED BY:
OFFIC