27919 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO.
APPLICATION/PERMIT PLUMB NG BUILDING DIVISION - BUILDING PROJECT IDENTIFICATIONc.
B UILDING ADDRESS:n/ SANITARY NO. APPLICATION SUBMITTAL DAI
1012v �E 1 j UNIT# yf# / T �fiv,.iin Ar
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC R CONTROLn
m. J F
RCHITELT/ENGINEFR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: v'y T; ^
QTY.A. ��YYst'P.LECIRIC PERMIT' j xT t '-.>�^FEB ..-+••Pr iT+ BUILDING PERFIlT-INFO .'
Ty–mi
I�^ �( t� y BLDG ELECC�� PLUMB MECH
' ' `\ i v F 41–oc, o 1 PERMIT ISSUANCE ❑ y� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL tot 'll–OB�DFSCRIPIION
Oremmm
l I hereby effort that l am licensed underpvisiansufChepter9(coencing wiwith,F tF and Section mf Division J mf Ne Business had Professions Code,and my licrnx is in PANELS
C U U full to. effect. ^
pa-,Zw License Clara Lic.p UPTO200AMPS
rn=y Win Comacmr 201-1000 AMPS �,�T//NTT�I♦r
Z��Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
1 understand my plans shall be used as public records.
=vt F nl SIGNS ELECIIUCAL
Licensed Profinaxond
x y.CQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/NUSC.
KOaU I hereby iffmt that 1 am exempt from the Conuacmr's License Lew for the
:YL u-a following raison.(Section 7031.5.Business and Professions Code:Any city orcounty TEMP.METER OR POLE UST.
w J which requires a permit to construct,¢Iter,improve,demolish,or repair my structure
Mnt7 pnorm iuissuutce,uses requires the applicant forsuch permit to file a signed statement POWER DEVICES
W 50 Nat he is licensed pursuant w the provisions of Ne Connections License Law(Chapter
m.z: 9(commeeeing with SecnimnT000)of Division 3.fft Business said Prefenicen Code) SWIMMING POOL ELECTRIC VALUATION
W—, onhm he is exemptaherefrom and the basis for dre alleged exemption.Any violence of
F Z_Q Senion 703 1.5 by any applicam for a Norm subjects the applicant in e civil penalty of OUTLETS-SWITCHES-FIXTURES
ce 0
nut more Nan five hundred dollen(5500). NEW RESIDENTIAL E1.ECIR_SQ.FT.
a_p ❑ Lasownera(Neproucture mycmplayeeswiNwageu Ne(Sm. B,sa.Buadan. STORIES TYPE CONSIRUCHO`
3= will da the sions and fliis The Comisn ts's Lice
.LaaaeA Foran apply to 14.Bones
and er"h obuild,.,
is Code:The improve.
comtar's nd who law does not apply lf,t owner of
progeny who but Ids or improves Merton,orW who dm such winds himself.,through his
emplayees,ptovior improvement
int is sold
owithin neintendedoroffawn.lnuna.IL OCC.GROUP RES. NTfS
however,Nebuilding tarimprovemenn ishathe did oneyeuo,improve
omm eforN pos,of TO
builder will have the buNen of proving that he did or build or improve for purpox of
645 2-
ale.). C:-''.en.e _"+a:.-w�... A. v_. �y i�+y d.
❑ I.asownerofihepmNny,amexclusivel conmctin Nlicens cmn Comm 4,"" aA
QTY. ,m.�4PLUMBING PERMIT',e: � +FEES-�a FLOOD ZONE APN
Y 8wi ,has niS<k:. icwnt',r[taM`N'`C_
construct nv project(Sec. arm Business eof,s and Professions Code:)The Canen,and
whoc La mfmsuc apjmtsnmwnero(prtms)liwho buildaorimpmvee N,eco a PERMITISSUANCE
wicensemcu fmsucM1pmjecuwiNacOaaactrn(a)Ilttnad pursuantbNe Canrmcbra ALTER-DRAMA VENT i�, K",
License Law. ( 1 ,.,.a;@ c'otiiP.' ?FEE SUMMARY.^
1 am axe t under Sha. ,B A P C for this seahan
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Ownc Dare DRAWS-FLOOR,ROOF,AREA,GOND. RECEIPT•
ork
WOR COMPENSATION DECLARATION SCHOOL TAX YN
❑ IIt..byaffimt Ihave ac.nificide.f.roommself.imurt,orecenificaeof RECEIPT#
Wera Ounissratioul.mnce maccrdfesimpy Nasof(Sec.3800,IabCJ which FIXTURES-PER TRAP PARK FEE Y_N_
null employee's under his peanut' GAS-EA.SYSTEMA INC.4 OUTLETS RECEIPT'#
Polity a BUILDING DIVISION FEES
Company GAS-EA.SYSTEMAVER 4(EA) PLANCHECK FEE
❑ Cenmed copy is h eby fumishM.
❑ Gasified copy is fled wiN the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted if Ne permit is farms,hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I cenify that in the Performance of Ne work far which this permit is issued,Ishall WATER HEATER W/VENTIELECTR
not employ any peon in any roomer ay as oye Whiner to the Workers' PAID
Z
Compensaionlawsmf Cnifomia. Dmr4FYO–")t WATER SYSTEM.TRFATING Dam Receipt#
Applicant
C NOTICETOAPPLICANT:lf.dt making NUCadfcaeof Exempd..youahould NBWRESIDENTIALPLMB. SQ.FT. TOTAL:
F becameauomploNn Worker's Comps w tus Permit min of Nelabor revoked.
mush
foMwiN comply wiN such provisions or this Permit shall be domed revoked. BUILDING FEE
yA CONSTRUMON LENDING AGENCY SEISMIC FEE
:D z I hereby affirm Nal them Is a conseucnon lending agency for the performance of
U O Ne won for which Nis permit is issued(See.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender'.Name lsav PLUMBING FEE
U' U Lender's AM. QTY; 4 ICA)P s b`'ZL` ~... a
C' Q'iY',n*�,,-f .,uc.c .;Ts,-.....0 ~ CSsi.Q Aa�FEB +'3:4
I certify Na I have read Ni.city
anal
cou and roe Net Ne above information is
)+ Til MECHANICAL FEE
Uybuilding conseemcomply with nlbiry air ceunrymdines.fibM sure lawsrtHnngN PERMIT ISSUA E
ubovengcoummil rn,aM herebywNonpurposes. vas of Niscitym<nterupon the CONSTRUCTION TAX
L) z ubmv(We)agree to save,
for inspection keepuxs. ALTER OR A TO MECH.
1 We) d,ne m ave,and expo end kap hamlea the City of Cupertino against
liabilitiea.judgmrnts,costs andexpem hichmay in hay we accrue 'mucid Ciry AIR HAN WG fTO 10#CFM)
in cohe L riong m Ni R tin. /
/d AIR H OLMG OVER 1 )
Siena u46-
reo Applican/Conr Data E ABST /DU
PAID
HATA'r'"MATERIALS DISCLOSURE HEATING (TO IOO,W�BTU) Dae Reeeips#
Will Ne applicam or future building..W,stem or handle haseNous motorial HEATIN U T(QVE U) TOTAL:
as defined by the Cupertino Municipol Code.Chapter 9.12, it the Heuhh had Satiny
CWe.Section J2p1'
❑Yea
❑No T TION (S)I1CLE IDI
ISSUANCE DATE
Will the applicanmrfuwre buildingocoupom Us c4uipme tordevicea which tad:
Bo ER MP { R IM K)0 BTU)
avadnus air comaminants as defined by the Be,Area Air Quality Munogemrn
BOIL: -COMP(OVER IW BTU)
ISViCL'
❑Yes ❑No NEW REST ENTIAL MEC SQ.FT. �.
I have read the luamduur.,coal.ristmixtrom.under Chapter 6.95 of the
California Hiodth A Safety Cade.Sections 25505,25533 and 255X. 1 unciemand Nat
if Ne building dorsum currently have a tens,that it is my responsibility mnmify the APR 10
occ.Pum of Ne requirernems which nun he met prior,m isanance of a Cmificam of 'O
Occupancy. v7
LIj
Owner nr omhnrized agem Dae TOTAL: ISSUED BY:
OFFICE AW