27551 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IRILDINLL= PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27551
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS/: E
I Nr/� _ I J [�7/aa/k SANITARY NO. APPLICATIO SSUBMIITALDAT
�V7 `^ i UNIT» ' LOTH
OWNERS NAME: _ _ 1 PHONE: CONIBAGTOR'S NAh m` LIC NO:
aGl�n/zwOhYl N IV" N!)5 N/C CONTROLN
�ARGIl1'MCTMNGINEER: LIC NO: ADD SS
»0 6o 34 kl9 5 S CA RSI S(� ❑
CONTACT: PHONE: t { X M1 '.
gLkT_RiC PERMIT- " FEE
BUILDING PERMIT INFO
R/ens » d','VVm ELECT PLUMB DESC IPI'10 MECH
PERMIT ISSUANCE �Y7'. ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I�'
Me;y hereby affirm thetlam licensedunderprovisianaofChapmr9(commrncing wish
b fail ion]and of Divis' J of Ne Business erld Rofessions Code.and my liana is in ppryp�5
<z Licen rce and effe AMPS
Fy LicenseC Carr r `da-*' UP T01 AMPS
m DN Dale GanlTS D 301-1000 AMPS 8 FT.FLOOR AREA 5/SQ.PT.
ZOs`nir� ARCHITECTS DECLARATION OVER IOW AMPS Q
O Z^QQ 1 understand my plans shall h used as Public recaNs.
Fa y�W SIGNS ELECTRICAL
9295i<F„,j Licensed Professional
c k!U OW NPR-BUILDER DECLARATION SPECIAL CIRCUIT/MIBC.
O 1 hereby n.(Su that 1 am exempt from the Contracm imnse Law the
3 4 y following reason.(Section 70315,B,aincss rnd Profusio We:Any city taco TEMP.METER OR POLE INST,
�Oy5 which requires n permit ne construct,alter,improve, oil me.sill any amucm
Sa'µyG��<C In,heI,inersedgvlsarequim the eppions of the pe us Licrs, memvn POWER DEVICES
W CGO Thaiheislicensedpunumtmtheproviaienaofthe Co ain't LicenseL'I peer
°'6�0� 9(thatheis cxm t emfmmwd) ebivision3of wend Rofeaa' ode) SWIMMING POOL ELECTRIC VALUATION -
yl'^^rn or shat heisexempt therefrom end the beaisforth leg ua cmpm to�n t on of OUTLETS-SWITCHES-FIXTURES
CyQ not on]031.5 by lummealicrnlrsI permits era the x'cwtm I nelty a( 7 (/
not momthinfivehundred I"m (SSW).
�F^'p ❑ I,erowneroftheproperly,ormy< yenwith I�Compemsetio NEW RESIDENTIAL ELECTit _SQ.FT. STORIES TYPE GDN$TR LTION
C
y3a.° will dothewon,ands: he Con
mendedoro s a Wan,Basin s
and my.h ons Coda:The Con Fs Licrnx nal apply to an own iof
s
ownpr.Iedywyces.mvidIdprnv ii n,aon, who an hwore oroelfonhmu Na OCC.GROUP RES.UNITS
nwnemployces,pmvidedth ch improv noti^^��n cdorofferW for e.IL
however,thebuddingor improve missal one yeei\(completion,the wast- TOTAL:
builder will have the burdrnofpm that he n buildorimproveforp of
sale.). 4 "
❑ I,asowma.fthepropeny,em exclu slycontrecdarg with licensed c waomo �ti!^ �'� PLUMBING PERMIT FEE FLOOD ZONE APN
caveman the project(Sec.]Ona,Business Professions Code:)Th oramctats
LircmeLewd.rx..pplymrnownerofprope whobuildsorimp sthereon,.od A
PERMIT ISSUANCE
who contracts forsuch projects with acomractor(s) pursuan the Cmussams
License Law. GIA)A) FEC•SUMMARY
❑ 1 um cacmpt under Sec, &P C for this reason BACK FLOW PROTECT.DEVICE SANITARY TVD N
Owner Dme DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
[3 Iherebysfflmthetlhuveammifcuteofcor nimaelf-insum,oramnificuteof FIKTURf•S-PER TRAP RECEIPT»
Workers'Compensation Insurance or a ceniftedcopy thereof(Sec.3800,Lab C.)which PARK FEE V N
cavenallemployeesunde fluspernit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy» BUILDING DIVISION FEES
Company GAS-EA.SYSTFM OVER 4(EA) PLANCHECK FEE
❑ Certifiedropy is hereby famished.
❑ Certified copy is filed with the ciry inspersion division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF.TRAP SOILS FEE
COMPENSATION INSURANCE
(This eecdon need ambo completed ifthe pertnitie for one hundred dollars(SIW) SEWER-SANITARY-STORM EA.20DPf. ENERGY FEE
or leas.)
I cenify that in the performance of the work far which thispemtitirissued,l shell WATER HEATER W/VENT/ELECIR
not employ any person in any manner so as to became subject to the Workers' PAID
Compensationl.awaof Cslifomis. Dam WATER SYSTEM/BEATINO Date Receipt
Applicant
Q NOTICE TO APPLICANT:If.efmr making his Certifiesmof Exemption,youshould NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
t—I r/] became subject In the Workers Compensation provisions of the Labor Code,you must
FF^^ forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE �»
C (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a commotion lending agency for the performance of s
iJ O the work for which this permit is issued(Ser.3097,Civ.C.) T ELECTRIC ME
I�-++ Lenders Name +,.'DPLUMBING FEE" t^ Lenders Address QTY, 'MECHANICAL PERMIT FEE
WI cenify that I have read this application and state that the above irthoonmicar,is th` MECHANICAL FEE
a
cateres.,I agree to comply with ell city and county ardinsmas and store laws relating to PERMIT ISSUANCE
buiIdingconstruction,and hereby au horiu representativeeof this city to enteruponthe
"ZZ above-me property pe puryos CONSTRUCTION TAX
migredfor ins coon a. ALTER OR ADD TO MECH.
(We)agree r leve,indemnify xx d kap harmless the City of a against
id City
liubilitics,judgmcau.cosu undexpcnses which may inany way eccmeegainst said City AIR HANDLING UNIT(TO IO,OW CFM)
in cc (the lfrantin8 of is permit.
uen . a C- /JS_ karma (p7 - IR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/ConR i`�/ ` Dalm(/ EXHAUST HOOD(W/DUCT1 PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I0(1,000 BTU) Date Receipt
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.0a)BTU) T -
Cade,Section 25532(.)? VENTILATION FAN(SINGLE RESID)
El yet ❑No V 72
ISSUANCE DATE
Will the applicamorfurumbuildingoccupent ussequipmentordeviceswhich emit BOILER-COMP OHP OR 101,000 BTU)
S hazardous air contaminants M definW by the Bay Am Air Quality Management BOILER-COMP(OVER 100,00)BTU) P A D
mi't?
❑Yes ❑No NEW RESIDENTIAL.MUCH.—SQ.FT.
1 have read the bacrdous materials requirements ander Chap.6.95 of the DEC 121994
California I loath&Safety Code,Sections 25505,25533 and 25534. 1 understand that ^
ifthebuilding does not currently have ast the et itis my responsibility enotify the V//y
occupantan of
y.the reyuiremente which must be met prior m issuance of a Certificate of Guy ur (e(yf+t�//
Occupancy.
Owner or umhnrized agent Data TOTAL: ISSUED BY:
OFFICE