27971 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BllHI.INt�13i,1[CTRTCA, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 7 0 7�1
BUILDING DIVISION BUILUIN'G PRIIJF,CT IIIEN'1TFICAl'ION 1 9 f 1
BUILDING ADDRESS: Q� [`fig^/ SAN) E.
LARY NO. APPLICATION SUBMITTAL DAT
I
O�(�v �r)�a y• `a UNIT# LOT#
OWNO PHONEC ACTOR'S E: �dLIC
\�NO
OIL— w
� N/C
CONTROL#
ARCfI"fEC/GNCINIEDRESS:�KQAS14 ^2 `, ❑*CONTACT: PHONE
BUILDING PERMIT INFO
TY. ELECTRIC PERMIT FEL
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ eK ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Oy.Z I hereby affirm that l am licensed underpmvisions ofCTapt<f9 usaunencing with TOB DESCRIPTION
�V O TOF.. Senior RWO)of Division 3 of the B liners and Pmfessio s Code, d my license is in PANELS /'• �.,�rt`A
FZw Lll luran cenx Cln raffia # UPTO200AMPS S i G"A..99
w 6 a IT ta Contractor 201-1000 AMPS
F m Z A '11 S DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
ZOvn - 1 n,cnrdfl e OVER IOOO Afr1P5
O< W p a SIGNS ELECTRICAL
Q � sN r asimal
a9�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
KOaU 1 hereby from that I sum exempt from the Cmaosctors License Law for Ne
FaON following reason. 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE 1.
oi which m tedues a permit to construct.alter,improve,demolish,m repair any sweom
Er�}� prior N its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
trajC D0 that he is licensed pursuanno.he FmOsiona ofthc Contractors Lt..Law(Chapter SWIMMING POOL ELECTRIC
a%o�' Y(commrncing with Section 70M)of Division 3olThe Business and Professions Code) VALUATION
,Mo, ar thin he is csempuhcrefrontnd the basis farthealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
1—Z� Scetion 7031.5 by any applicant for a pennit subjects the a pplicant..civil parch,of
m Nn afive hundred duller:(Sial).
cczC nmar< unNEW RESIDENTIAL ELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
yz F_o ❑ ohewrk,andcpropeny,mmycmpendedreofereg mrsak,(See.7ompeveuon,
3� will darhework,aodc:The
hreis Countenances
not cenLicese Law
red does not apply
ss
of
and Profession.C«le:The Contracmrs License Lew tints not apply m an owmr of
property who builds or improves Nercem and who Nes such work himself or through his
owo employees,provided thatsuch impmvememsamnot inundedoroffimed foraale.If.
OCC GROUP RES.UNI"fS
however,the building or improvement is sold within one year of completion,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE HOOD ZONE APN
❑ 1.a ownerofthepropeny.amexclusivelycontmctingwiOlicemedcnno—,r10
construct the project(Sec.70,14.Business and Professions Code:)The Convector's
Lic.seLe doe.natapplyuanownerofprop<nywhobuildsorimprovesthercon.and 1, PERMIT ISSUANCE
whoconvacts for such projects with acontrectuds)licensed pursuaouo the Committee., AIfIER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. .B&P C for Nis main BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Ilam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMP[NSA'TION DECLARATION SCIIOOLTAX YN
❑Workers
Cro .bfirm NeO hamix, aticxx ofcanxnursaf(Smure,o.Lab C.)which
hich FlX'ILRES-PER TRAP RECEIPT.
covers
crehiyea'ionlnsumncearucenified copy[h<rmf(Stt.3800.Lab C.)which PARK FEE Y N
Pavers all employ«sunder this permit. GAS-FA.SYSTEh1-I INC.4 OUTLETS R
Polity# BUILDING DIVISION DIVISION I'IiE$
Company GAS-EA.SYSTEM OVER 4(FA) PLANCHECK PEE
❑ Cerifinde.,isherebyfumished.
❑ Cenificd copy is filed with Ne city impaction division GREASESNDUSTRL WASTE INTERCEPTOR GRADING FEE 'Ia
CERTIFICATE OF EXEMPTION FROM WORKERS' GR AP SOILS EEE
COMPENSATION INSURANCE'
(This section need notion,completed ifthe permit is forme hundred dollars(SIM) S ER- NITARY-STORM EA.200FT. f ENERGY FEE
odes.)
I certify that in the performance ofthe work for which this permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ any Janson in any manner so as to become subject to the Worker' PAID
Compenastionlswaof Califamia. Date WATER SYSTF.M(IREATING Date R<eipt#
zz Applicant NEW RES I DENT'IAL PLMB. SQ.FT. TOTAL:
z NO'T'ICE TO APPLICANT:ILefxr making NCertificate
isa(E mptio,you should
1) bcconsc ubjectm the Worker's Compensation provisions ofthe Labor Cade,you must
� > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDIN IEP
1 Q
CONSTRUCTION LENDING AGENCY SEI IC iG
z 1 hereby affirm Nat there is a commuca on lending agency for the perferm mon of El T PEE
U O the work for which Nis pe.i n is issued(Site 3097,Civ.CJ
Lender's Name FLU IN FtiE
0 F1 Lender'.Address QTY. MECHANICAL PERMIT FEE
U I certify that I have read this applicmion and start that the above information is MECHANICAL IEE
>" contest.)agree.comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE If
L" buildingcousuuction,and hereby amboriu representatives ofthis city. m
merupohe CONSTRUCTION TA
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL
(We)agree no save.indemnify and keep hofmlos the City of Cupenina against
Iiubilducti,pid co sand<epersus whichmeymanywayaccmeagame,acid City AIR HANDLING UNIT(TO 10,M)CFM)
in cofnhegr tingofthlsperrou.
ili MOM�j AIR HANDLING UNIT(OVER CPM)
Comore Applicant 5mowto ^Date EXHAUSTHOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT'(TO IW.000 BTU) rte Receipt
Willtheapplicant or boom building occupant Stam or handle harallous mmerial HEATING UNIT(OVER 100,000 BTU) TOTAL:
m definW by the Cupertino Municipal Cade,Chapter 9.12,and the I Icahh and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RISID)
❑Y. ❑No
BOILER-COMP LIHP OR IM,M0 BTU) d$SUA 'E
Will air co tra inamsuasb arming by thenmx equipment ofaliq Management
it R �/
�'mous air contaminants as def red by the Buy Area Air Quality Managemmv BOILER.COMP IOVF;k IIXI,IKKI ETD) �i
t[IriPR
❑Yes ❑No NEW RESIDENTIAL.MECIL SQ.FT. r $/9 (w
h l /
1 have read the Safety
Code
materials requirements under 34. 1 Chapter understood
of the
Calle buia I lding does
not cp CnJy have anent.that
is yrespund 34. 1understand tihat
the
if the building docs not m currently w have a tenant,that it is my respnce dila Ce notify the V
• cam.t of Ne requirements which mute)bP over prim to Is.uunec of u Cenificam of
rampmty.
Owner or nwhadmd agent Data TOTAL: ISSUED BY-
OFFICE
Y:O I
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd., Bldg. C PRS:
. Cupertino, California,.95014 CHB: _
(408) 235-7071 AEF:
File:
"OVER THE COUNTER REVIEW
Date: fvr^� z_4
File: CuSD- MOP
Building Dept-Cupertino
Community Development Department- Building
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014-3202 f(
Re: Subject: Cohr\Pc-1�w1
Name: Gf 0 5 2 r-r 0 j
Address: /0 3'10 /Via 7 H Ar
APN: 32(o —�S —DO
Control/Plan Ck No:
Permit No: / S¢ -7 0
Gentlemen:
The Cupertino Sanitary District has reviewed the plans for the subject project:
• 9-- No additional fees or permits required by the District.
❑ Sanitary sewer is available and the existing building is connected to sanitary sewer.
❑ Sanitary sewer(is)(is not) available.
❑ Sanitary sewer is not available. Refer plans to County Health Department. ,
The following Conditions/Requirements are made:
❑ Cupertino Sanitary District Fees or Permits are required for the subject
improvements please do not issue any building/grading permits
❑ Plans must be submitted to the Industrial Waste Division of the San Jose/Santa Clara
Water Pollution Control Plant (Phone 945-5307) for their review and recommendations
for pre treatment device requirements. Please Do Not Issue building permit until these
requirements have been transmitted to you by the District.
❑ Locate and raise to grade a property line cleanout.
❑ Install a backflow protective device (verify serviceability if existing.)
❑ Break areas authorized minor electrical appliances only.
❑ No disposal or dishwasher installations.
❑ No added lab/office equipment which results In additional waste water discharge.
❑ Other. .............................................................................................................................
The condensate from any HVAC equipment, surface water or I'm g ion water shall not be discharged to
the sanitary sewer.