27527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HIM LVING-ELEUrRTCA' PBRMD'NO'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n C
BUD DING PROJECT IDENTIFICATION G J
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATE.
(sL{ eAl//-e_ UNIT OW / � / V C
AMEQACTOR'S2yY
A LCNN/C CNTROLN
A CHI
Ip3NGINEER: LICNO: ADDRESS: ❑
""A"41-SPS-0
COMPACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
�"z� 1/ BLDG EL PLUMB MECH
. ,u/(/� �/ �'�i T��]Cj PERMIT ISSUANCE
LICENSED CON CfOR'S DECLARATION LOB DESCRIPTION
APPLIANCES-RESIDENTIAL,
y�y Ihcrchy affirm that lam licensed undcrprovisionaofCTepter9(comrmnuncing with
00 Sectiams0 7")of of Ne Business and Profession Code,and my license ism PANELS � �
'UF full force and effect.
I¢„Z, License Class Lic.p UPT02NAMP5
yjy Dale Contractor 201-1000 AMPS
IZO'z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
O Z C tp I undertmnJ mY Plans shell be used av public records. OVER 1000 AMPS
Tk
SIGNS ELECTRICAL 2��
hCQ Licensed Professional OWNER-BUILOFR DECLARATION SPECIAL CIRCUFDMISC. r
a F 1 hereby effimr rhes I an exempt from the mr
Camrn 's License Lew for the
sr] 0.•m following reason,(Section 7031.5,Business and Professions Code:Anycity or county TEMP.METEROR POLE INST.
uJ which rnpmims a permit to construct,alter,improve,demolish,or repair any swctura
� prior to its is so.nonesonequirestheapplicam fir such .I,to filo.signed stounum, POWER DEVICES
m ty O that he is licensed pursuant to the provisions of the Con ctors License Lew(Chapter
rMypeL 9(commencing with Section 7000)of Division 3 of snessand Professions Cade) SWIMMING POOL ELECTRIC VALU/A�TION
J)Z, Sectio M1ei.ve.5 hyayapfic and the permit th leg txemanato civilonaltyof OUTLETS-SWITCHES-FIXTURES
FZa not Section bya undredicollars .permit jeenhea licanuoecivil penalty of J "'I
fF0
not mom ,of,hi eope"lers(ES NEW RESIDENTIAL ELECTR _SQ.FT.
K 22 ❑ odo,w,k..deproperty, employodmoeredfor tMirsole044,13 mon. STORIES TYPE CONSTRUCTION
y3— will J- work,wda nommi inticense Law
e(Sec.JB 14,Business 6S 1 r4`53
and ' c:The vesftm's License Law does no apply lf an owner of 77
pm ywhnbuimvi impmvesthimpwvmcnls notihw himuoubtfooec.1f. OCC.GROUP RES.UNITS
employebuildividedmprovehimpt, Id msem mycarnf.rmffcreddx We.IL
no r,the willaveTieng urien ofpmrntis Idwhinalailro(corpledom,rmor-
buiderwillhaveNebudrnofprovingt t no build or int vat for purpose of L'
sal .). QTY. PLUMBING PERMIT PIT FLOOD ZONE APN
❑ I,as crofthepr perry - lu yconame tin lice dcontmctorsto
cons um rhe prnjcel(S 'I ess and Prmfe. ns Code:)The Contractor's PERMIT ISSUANCE
LicenoLuwdoesnmupl crafpmpeny ohuildsorimog
provesthoeand _
whoc tmerhasuc withacontmcmr iccnudpunu.ntmthe Commoome ALTER-DRAIN&VENT-WATE0. EA s'
License .sew, ( ) FEC SUMMARY
❑ 1. asempt under c B&P C for Nis reason BACK FLOW PROTECT.DEVICEOUTSIDE FITS
SANITARY Y N
Owner Dau RECEIPT it
DRAINS-FLOOR,ROOF,AREA,CONO.
WORKMAN MPENSATION DF.CIARATION SCHOOLTA% YN
,❑ IM1emby affirm mhep eacenificam of conunnm telt-insure,orecertificme of RF.CEIPI'M
FlXTURES-PE TRAA1s
Workcr%Con enation sums ore cenified copy thersel(Sec.3800,Lab C.)which 1 PARK FEE Y_N
eoversdlem nyoo' oder this pemtit r.c FA -IINC.4OUTLETS RECF.IITg
Policy is 4- BUILDING DIVISION FEES
Company OAST- ^. -OVER4 UA) PLANCHECK FEE ��
EI f.asrificd copy is hereby furnished. ;:�
FB Cenificd copy ie filed with the city inspection division.` " .t ' 7GREgSF USTRL WAS INTERCEPTOR GRADING FEE a..w.
CERTIFICATE OF EXEMPTION FROM WORKERS'/'� g ./ SOILS FEE
COMPENSATION INSURANCE r� )
U09 L
(ns section need oar be completed ifthe permit is formas hand lore($I ,e$B . -SANITARY-STORM EA.200FT. ENERGY FEE e
m less.) A.Stee�,a
I comfy that in the performance ofthe work for which this psrmi pgh� � WATER HEATER W/VENT/ELECTR
not employ any Person in any manner so as to become eubjxt the Worker' PAID
Oz
Compensation lrwsmf California. Date •s y'.. WATER SYSTEM/IRFATING Date Rec tp
zC) NOTICE TO APPLICANT.If,after making this CmiOcau of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
became,subject to the Warksn's Compensation provisions of tho Learr Code,you must 1'�
� � ecefonhwith comply with such provisions or this permit shell be deemed resulted. s7.. BUILDING FL ss—It
CONSTRUCTION LENDING AGENCY SEISMIC
VZ 1 hereby affirm that them is a construction lending agency for the performance of
O the work for which this permit is issued(SIL.3097,Civ.C.) L ELEE
Rs r.t Lcndcrs Name
t' Lender's Address QTY. MECIIANICALPERMIT FEE PLUMB C .E
U I certify that I have read this application and state the the.bone information is
Ha career. Iegre,m comply with all city and county ominancee and state laws relating m PERMIT ISSUANCE MECHANICALFEP, `
� building construction.and hereby authorize representatives of this city to enter upon the
(••) 7 cRI
love-memimed pm,ny fm inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION fX
a (We)a me Iave,indemNfy end keep hmmleas the City of Cupertino against
liabilities' gmm
en ,enuandexp nseswhichmay' acemea ainosalCity AIR HANDLING UNIT(TO 10,"CFM)
incons�enceof Nsgnading ispisp AIR HANDLING UNIT(OVER 10,0WCFM)
Stgnamu of APPlicanUC cwt / Doe EXNAUST HOOD(W/DUCT)
PAID
HA RDOUS MATERIA DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dem _\"P.k
Will the applicant mfmure building aecupant mom or handle haoWouscraroria HEATING UNIT(OVER 100,000 BTU) TALI
as dcfired by the C.,mro Municipal Cod,Chapter 9.12,and Ne Health and Safety
Code,Semi 8532(x)?
11Yes ❑No VENTILATION FAN(SINGLE RBSID)
❑
Will air contaminants;
building by the Bay Amu equAir Quality Management
BOILER-COMP(3HPOR IW,OWBTU) ISSUANCE DAXE
Joneous air aomaminanu m deemed by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Jiorin7 Gl
E-]Yet ❑No NEW RfSIUENTIAL MECH. SQ.FT. 1� se�
I have nerd the hazadous materials requirements under Chapter 6.95 of the Spy '-7 1995
Culifomia I Icuhh&Safety Code,Sections 8505,25533 end 25534. I understand Net
if the building does not currently have a mount,that it is my responsibility to notify the
oecupam of the requirements which mast be ars poor to itss...of.Certificate of �I` L I O
Occupancy. I Y
Owner or outhodud agent Dam ISSUED BY:
Q