27499 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINOm)n:Dnrr,-eDUCAL PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT 1'I.UMBING-MECHANICAL 27499
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: lh SANITARY NO. APPLICATION SUBMITTAL MITE
I1 -l�aaW '(� UNITis LOTa 1r.3`.
OWNS NAMEq PHONE: CONTRACI'OR'SN ME: LIC NO:
O '3 N/C CONTROL M
1is
ARCHITECT/ENGINEER: LIC NO: ADDRESS:_ un� / EliLQQ�� N b
CONTACT: PHONE: 1-i,;tt 6 �f" Z� " ' BUILDING PERMIT INFO
QT 'k .,^ �1.&.(6T4R�IM PERMIT,- FEE
BLDG Fy,ECf PLUMB µ�FgC{H
PERMIT ISSUANCE
LICE.NSEDCONTRACfOR'SDECLARATION APPLIANCES-RESIDENTIAL I����aCeror�l / v
GCZ (hereby affirm CENSEDCO TRAC CONTRACTOR'S
proviDECLARATION
(commencing wird
Y100 Senion700fjof Division Sof the Business and Professiom Cale,and my license is in PANELS
full force end if _1`3
,Zw LiveLic.p UPTO200AMPS
mQy Dai Conuuaor 201-1000 AMPS
ZOyZ ARCHITECT'S DE RATION OVER IWO AMPS SQ.R.FLOOR AREA SISQ.FT.
OZ-0 I andersaind my plans shall be used as public records. / /u
PNtJSIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
li OyF 1 hereby air.chat I am exempt from the Cantoccooa License Law for the
W30.m following reusnn.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Om�j which requires s Permit to construct.alter,improve,demolish,or repair any stmcmm
>� priomoitsissuance,also regaims the applicant forauch perrium Eleasignedmitemem POWER DEVICES
GC, that he is licensed punnt
mam the pmvisioosofthe ContractorLicense Law LicenLaw(Chepter
a yo44.. 9(commencing with Section7WO.I'Division 3ofthe Businessand Professions Code) SWIMMING POOL ELECTRIC VALUATIONN%lr_
y_¢y
,in.,he is exempt therefrom and the basis far theallegcd exemption.Anyvioliumno! OlIT1.Ef5-SWITCHES-FIXTURE$ :1 O
x a Section 7031.5 by any applicant for a Permit subjects One applicant to e civil penelry of `
C� not more than Eve hundred collors(SSWO.
ad ❑ I,mownerofthepropeny,ormyemployeeswithwagesastheirsolecompensaU'on, NEW RESIDENTIAL F.LFiCTR _SQ.IT. S'T'ORIES TYPE CONSTRUCTION
will do me watk.md the mna,mre knot intended crofferd forsxle(St 7044,Business
and Professions Cash:The Cantrecmr's License Law does no,apply to an ower nof
pmiperty who bui Ids or improves roamer,and who does such work himselforth ough Ns
mvinemployces,providedthm such improvementsum not intended craft for sale.If, OCC.GROUP RES.UNITS
however,the building Wimproveracon is sold within one yewofcompletion,themener-
builder will have the burden of proving that he did nm build or improve for puryose of
❑ las awnendthe pngacdy.emexGusivelyamOnd ngw thl censd canhxcta PLUMBING PERMIT x .FEB FLOOD ZONE APN
Qdr i a
consvuct the project(Sec.7014.Business and Professions Code:)The Cona a, r'e PER -UANCE
Licenu lawdocsnotapply m anownerofpropeny who builds inimproves,hereo .end
whoempacts forsuch projects with econtrocmKs)licensed paruonumhe Can emr's ALTER-DRAT VENT-
WATER(CA)Livcnse Law.' FEE SUMMARY
❑ I em exempt under Sec. ,B&P C for t s o HOW PRO TE DEVICE. OUTSIDE FEIN—
"Irk"",
EIN
SANITARY Y N
Owner Data RECEIPT.
D 5 Fi R,ROO YEA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a emifcom ofconsent to self-insurs, acenlEcacof RFCP.IPT.
Waders'Compensationlnsumnce oruttnifidcnpy Ohermf(Sec.3 ,nab C.)aedeh ES-P:R P PARK FEE Y_
covin all amphlea's under this Permit. GA -EASY - INC. OUTLETS
RECEIPT.
Policy. BUILDING DIVIS S \_
Company S-EA. ST.M.OVI?I2 (FA) PLANCHP.CK hiiF.
❑ CenifidcnpyishembyfumisM1d, on
❑ Car iftdcopyisl dadwilb,be ciy inspecomil' GRFASEBN STRL WAS' --INTERCEPTOR GRADING FEL!
CHRTIFICATEOPEXEMPTIONF MWORKF"RS' G121? SOILS FEE
COMPENSATION INSUR E
(TMs sec,ionned not be completed ifdte permit is for hundred dollars(SIOO) .WER-SANITARY-STT EA.2OOFT. ENERGY FEE
or less)
(certify that in the perfonnence of the work for whienthisperm issued,(she ER IIfATTiR WN[NT LECTR
not employ my Person in any manner so as,o become subject to Worker% PAID
Compenmtion Tawsof Califomia. Date WATER SYSTHMTREATIApplN Uate Receip,p
O Z NOTICE TO
Z0 NcomesTOAPPLICANT:Worker's
after Compensation
NTSovisiosofthficam,of Exemption,you should NEW RESIDENTIAL PLM SQ,FT. TOTAL:
(~-' becomesubjectthe Worker's Compensation pmmisioaillbeelaboromisM. mull
� > lonhwi,h comply wird inch provisions coni%permit sha116eJamd revoked. BUILD G
(� CONSTRUCTION LENDING AGENCY S17ISMIC FF.:
I hereby affirm that There is a construction lending agency for Neper[ormmce of
Othe work for which Wit Permit is issued(See 3097,Civ.C.) T ELECTRIC FEE
Lenders Name -4 PLUMBING FEF,
0U Lcndels Address QTY. �.-'�MECHANICAL PERMIT .. .FEE
U - 1 can By chat 1 have rend,his application anti state that the above information is 0.t '
1 onrri.Iagree to comply with all city and county otdinunces and state laws mhting to PERMIT ISSUANCE MECIIANICAL EE
bdilaingcm,aummur,end herehyamhurfm repreuntafivesof,his city to enterupon,he
U 7 move-metnimad property for inspection purposes. ALTER OR ADD TO MSCI I. CONSTRUCTNTAX
G (We)ugtcc to save,indemnify and keep harmless no City of Cupertino against
Iimilitics,judgments,cosu ondexpemesvehichmuy in my way accrue against said City AIR HANDLING UNIT TO 10.000 CFM)
co f,he gmmingivf this pe
/� AIR HANDLING fINIT(O VER IO,f100 CFM)
Ado
nater Appliesm/Cotnmem Date EXHAUST HOOD(W/DUCf) PAID
HAZARDOUS MATERIALS DISCLOSURE I[RATING UNIT(TO IOO.00p BTU) IN R.ipt 0
Will the applicant or future building occupant store or handle hazardous material
ns definal by the Cupertino Municipal Code,Chapter 9.12,md the Health and Safety HEATING UNIT(OVER I(NLOOK)BTU) TOT L:
Coda.Section 25532(x)? VENTILATION FAN(SINGLE.RFSID)
❑Yes ❑No
Willtair pplicarlor conaminafuturedefineg occupantuse equip mint unlit Manes agemmh
POILER"COMP(THE OR 100,000 BTU) SDN EDA r
mzerdoue air contaminants m define)by the Bay Area Air Quality Mmagemenl NEWBOILER-COMP(OVER IW,000 BTU)
❑Yes ❑No +n. 1
Jia,ridP RESIDENTIALMECIL SQ.FT. JAN V` 1995
/'sf
1 have meal the hazardous materials requirements under Chapter 6.95 of the " LINO
Culifomie Nealth&Safay Code.Sections 25505,25533 and 25534. I undatm
erd that (�' UGUh'EH "
if the building does not currently have a tenant,that i,is my responsibility to notify the
occupant of Lha requirements which most be met prior to Issuance of a Cenirenre of
Ocvapmcy.
Ownerormthoneadagen, Date TISSUED BY:
OFFICE