27558 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO LTLDING-MEC MECHANICAL pERMI'T NU.
APPLICATION/PERMIT PLUMBINJECT ICHANICAI.
BUILDING DIVISION BUILDING PROJECT IUEN9'IFTCAI'TON 27558
BUILDING ADDRESS: /,S /� / SANI'TARYNO. APPLICA'PON SUBMITTAL DATE
� �5/zeu) W.'1 I:NIT# '. LOT# 1�eL`
OW r S NAME: 1� PIIONI:: -��( C NTRACEOR'S NAME: ✓J L�G. J
V (J �^/II,M' JT / L,, ::�NIC� CONTROL#
.RCIIIT[CT/1iNGIN13LR: LIC NO: DIS.L � * �.$ 00Is S .�.)I LY',SZf,'j
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB CII
PERMIT ISSUANCE 0 ElLICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
mazz Ihereby affrm that l am licensed under provisions ofatiner9(cammenciagwith
FOO Section 7")of Division J of the lyrammss end Professions Code,and my license is in PANELS
yv WF GJI force and effccL ,L ?J
FZ" ate s Co..,.,c.p �/6 0444 UP T02fq AMPS
m- m
Date GTSD1 v-+�{.i 201-IIXp AMPS
GOY- ARCIIITECTS DIiCLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
OZ-0 1 undemund my plans shall be used as public memod.
F IL SIGNS ELECTRICAL
Qy7,'j Licensud Profbssional
a�a'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO W, 1 hereby affirm that I sm emai from the Cmaxisa is License law fm the
t+13LLm fallow ing m......(Section 7031.5.Business end Professions Cud.:Anycity or coan,y TEMP.METER OR POLE INST,
Owhich requires a .it m construct,alter,improve,demolish,or.epan any structure
,W}2 prior to it issuance,also romma the applicant for such Permit o file a signed statement POWER DEVICES
p)K�O that he is licensed pnimano,the provisioreol he Contractor's License Law(Chapter
axe 9(commencing with Section 7") Division J of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
m—,n or that he is exempt herefrom and the basis for the alleged exemption.Any violation of Of1T1 FTS-SWII'CHES�FIXTURFS '
LZY Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Q nos more than five hundred doll..(5500).
� O NEW RESIDENTIALELECTR FT.
C o ❑ hasowncroftheproperty,ormyemployreswiN wuguu,heirsolecompensation. —SQ. STORIES TYPE CONSTRUCTION
d2 will Jo the work.and the structure is not intended or offered for sale(Sec.J(H6,Business
and Professions Code:The Connors License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work hi bacifor through his
own employees,provided than such improvements ore not intended or offered for sale.If. OCC GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,theowner- TOTAL:
builder will have the burden of proving that be did clot build of improve for purpose of
sale.).
❑ 1,asownerofthepmp ny,ameaclusivelyconu tingwhhliansedcomrncsorsm QTY. PLUMBING PERMIT FEE PLOOD70NE APN
construct the project(Se.70a,Business and Professions Cale:)The Convaaor'a
License lawdoes not apply tomownerofproputy who builds or improve&&hereon,and PERMIT ISSUANCH
whocommem for such projects with acontractoos)licensed pursuant to,he Cintranor'. ALTER-DRAIN -WATER FA
License Law. (' ) FEE SUMMARY
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLAW P ,CT.DE CF, OUTSIDE FEES
SANITARY YN
Owner Dam DRAINS-FOO ,ROOF. R ND
RECEIPT al
WORKMAN COMPENSATION DECLARATION . SCHOOL TAX yN
❑ Thereby off Na,lhaveecenificam o(conunuo xlf-insum,macenifica¢of FIXTU E ERT RECEIPT#
Workera'Compensn,iun lnsumnce oracenified copy Nereof(Sec.)800,fabCJ which PARK FF,Ii yry
covers all employe',mak,,his permit. GA .SYSTEM- .6 fITLETs RECEIPT#
Policy It BUILDING DIVISIO FS
Company 'AS 'A.SYSTEM- ER 4(EA) PIANCHECK FEF,
❑ Certified wpY is heeby fumi.M1cd.
❑ Certified copy is filed with she city inspection division. GR ' NDUSTRL WASTE INTERCEPTOR
GRADING FEE
CHRTIFICATC OE EXEMPDON FROM WORKERS' GREA 'I P
COMPENSATION INSURANCE SOILS FEF.
(Thissectiun need not Ise completed ifthe permit isforone hundreddollars(SIW) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or les..)
I Cenlfy thus in the permormnce.(the work far which this permit is issued,l shall WATER HEATER WNENT/ELECfR
nm employ any p.r.on in city atonic,so as to became subject to the WorkersPAID
Compensation Lawsof Celifomis. Date WATERSYSTEMT#EATING Date Remi I#
z p
Applicant
V) NOTICE bjctto APPLICANT:WorkeI.r's
after Compaking ensation
prCisionseof Exemption,you yu mulct NEW RESIDENTIAL PLMB. SQ.FT. T- :
F > become suomptoric Work era Compensation prmitshalt beeLabor Code, must
� > fnnbwiN comply with such provisions.nits permit shall be deemed revoked. BUILDING FEE 61
1
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that hem is a cum,tranion lending agency for the perfommnceof
U O the work for which this permit is issued(Sec.YN7,Civ.Q) TOTAL: ELECTRIC FEE
Leadds Name
Q U 1-mole,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
r LL1 1 certify that 1 have mud this application and state that the above information is
Correct-I agree to comply with all city and county ordinances and state laws relating toPERMIT ISSUANCE MECHANICAL FEE
an
F-' building construction. d herebymumnee representaivesof Nis city I.en¢rupon the GGN$TRHCI7GN TAX
U z above-amtianed property for no,clion purpose,. ALT ER OR ADD TO MECH.
(We)agree m save,indemnify and keep ba cnless the City of Cupmir.against
liabilities.judgments,costsundexpenus which may in any way sccme again.said City AIR HANDLING UNIT(TO 10,010 CPM)
Z co.uyucnce of the granting of this permit
AIR HANDLING UNIT(OVER 10.000 CFM)
Signor Appl,cunl/Contmnor Dti I l:XF1AUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101.000 BTU) Date Receipt a
Will the applic I or future building occupant store or handle accordions material
as refined by the Cupcnin,Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOT L:
Cade.Section 25532(o)'!
❑yu ❑No VENTILATION FAN(SINGLE RFSID)
Will Nenppliconmrfumre building h, he Bay Am.Air unlit ecswhich emit
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
'mvcoos air nmmminams to defined by the Buy Arco Air Quality Management BOILER-COMP(OVER III0,0110 BTU7
ieTt I
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P A D
1 have read the h.dous materials mi imments under Chapter 6.95 of he
California l health&Safety Q,de.Sections 25505,25533 and 8536.I noncontract Nn DEC 1
if the building docs too cu
cooren ly have a mmed,chin it i,my responsibility m nobly the
pal of the requirements which mus,be met prior m issuance of a Cenifieam of
Occupancy.
I .anU
Owner W uahodred agent
Date ISSUEDBY
OFFICE
/3
Eau FED
utt, ls
1994
BLDG: IEC""' DEP
OF CUPERTI�p �{�Ti
APPROVED
IN ACCORDANCE WITH THE CITY OF 32
CUPERTINO CODES AND ORDINANCES
DATE.�
SIGNED
This set cf pLr c
be kpnr a "'eaficaliens MUST 53'
..T ua'es , /0
lav/ful to make ,; "nd it is un
On "„a,_.. / e""' '-s 0, alterations
_
�— the building Dept., .: :f t e,mssicn from
The starnpicr of Ibis
SHALL T be h..i t
NOT d '• FFecih^_ations
oc.;nit
approval of i`r vrlatior to be an
co cf any provisions
of any City th;,na
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