27593 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO RIRLDINC-F.1'F('TRICA i'
APPLICATION/PERMIT' 'LumI NG - MECBANICAL
BUILDING DIVISION , IIUILIIING PRO•Il:(:'f IDFNTIFICATION
PERMUNO. 27593 ,a
JU 'J!
BUILDING ADDRESS: ^
2Z�S5-A i2AucNa v�nirc��c�TT»CT 25
IAT##
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNERS NAME: PIjONE:
LAREK L AtcE L+4(o-S7e
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONTROL#
IRCUDICT/IiNGINEER: LICNO:
ADDRESS:
CONTACT: PHONE:
J, I
LAR.'%S' %� � vc a �•
4 6— S 3 — 1
* l v 's t 'rt?BUIT
QTY ;;LL, " #R�FLEGTRIC PI RMIT. -, _ - FEE
4kV tqv 81', 9'rt bl •" •'r,
DING PERMIT INFO
BLDG FL�' PLUMB ME❑CH
�1
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby arfrmlhnl l amlicensed under provisionsofChapter9(commeneing with
APPLIANCES - RESIDENTIAL
JOB DISCRIPTION '
> Section 'AI00 ts' Division Sof to Business and Professions Coda and my license is in
full force and effort.
1 Licmae Class Llc,p
Date Contract
PANELS
UP TO 200 AMP9
201 - IOW AMPS
] ARCUITF.CI'S DECLARATION
J I understand my plans shall be used as public records.
OVER IOW AMPS
SQ. FT. FLOOR AREA
E/SQ. IT.
SIGNS ELECTRICAL
Licensed Professinnnl
1 hatVI am BUILDER OF,C Contra ON
I hereby affirm thin 1 am exempt from Inc Cnsions Cs License Law forco the
SPECIAL CIRCUIT/MISC.
TEMP. MGTER OR POLE INST.
I Business and city or county
renes
(SectPermit
whichfollowing to Construct,
a
which inquires issuance, permit to construct, palter,plic improve, demolish, or repair any structure
improve, h. or re reAnypair
t, demolish.
requiresthe ch toes Elecoun d(Chapterement
nsliensedpursuant
POWER DEVICES
that hor
visiicns of the Commit
Law
j thinmisncingwpursuanttotoprovisionso(the theusiness Lice nu Law(Chapter
9 that heisexemith Seaion]OW)of Division Sof the ed exemption,
tio,Any iota Code)
of
mtnon7031.5 by therefromnt f the PeJsforteaRegedexemant to civil
Section 7031.5 than live 1$500). mbjenvh<applicennoecivil Pendryof
C hundred units,,
I urn mon, than hundred Jnllurs(8500).
❑ base wok, mtepropmy,ormycmpendedourofwageauthei(sale compensition.
SWIMMING POOL ELECTRIC
- VALUATION
OUTLETS - SWITCUES- FIXTURES
NEWRESIDENTIALELECTR_SQ.FI'.
S'IORIILS
TYPE CONS '1'RUCTION
will dothework, Business
Code: CmeranmintendedorofPo due. atapplyJ0.
and Profusions Cndc'fhe Contractors Licenu Law does not apply m nn owner of
property who builds or improves thereon, and who dao such work himself or through his
empinyas,pmviJulthin wchimpmvememe arcnot imm�ded or offered Tarsale. If,
OCC. GROUP
S. UNITS
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
-
QIiV�:'PLUMBING PERMIT FEE
sale).
❑ I,mownerofthe property,amexclusivelycontractingwitlicensW convactonto
FLO DZONF.PN
EA
Tmstmel the project (Sec. 70,14, Business and Professions Code:) The Contractors
ice ulawdasnot applym an ownendpropcny whoboilds or'unpmvu tereon.end
PERMIT ISSUANCE
whocomracts for such projects with a contracmr(s) licensed pursuant o the Contrecmrs
Law.
ALTER WATER (EA)
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this reason
BACK FLOW PROTF.Cf. DEVICE
O . ID . •E •'
OwnerDara
WORKMAN COMPENSATIONDECLARATION
❑ Thereby affirm thntlhavc ecenifcate ol'coneenno sal Ginsurc, oro eenifeme of
Wmkern Compensation lruuntnce oracmified copy tereof (Sa.36W,lab CJ whicM1
colics all employee's under thio pcmtil
Policy #
DRAINS - FLOOR, ROOF, AREA, GOND.
SANITARY Y N
RECEIPT #
SCHOOLTAX YN
RECEIPT#
•IXTURPS - PER TRAP
PARK FEE YN
RECEIPT#
GAS - EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION IBES
Company
GAS -EA.SYSTEMAVER4EA)
•as4�w
PLANCHF.CK FEE
❑ Ceni0ed COPY is hereby famished.
❑ Certified copy is filed with to city inspection division.
GREASP/WDUSACWASTR"..ttCEPfOR
GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .--r"'
(This section need notbe completed iffle permit is for one humindUdllios(SIW)
or less.) •;'.-
'GREASE TRAP ) 11
SOILS HE
S II - NI' R - ORM EA. 2801'1'.
ENERGY FEE
P. 'I /ELE R y
Ianifythttiothe pc rfomtaneeoftewofkform+tieh this permit is issued, hal
not employ may person in any manna w as to 1%'come subject..11i tEe� ona
r r `
Ca
ompcnution laws of C#li(omie. Dam
caol
PAID
pare R.ipt#
S T /JRf!ATING
NOTICFTOAPPLICANT:TLeflermaking,M,Ceni teof Eacmp y1 ab�
nes:ome suf,,jectmthe Workers Compensation provisions of the Leben jaix ,ytwmand
N I : li. Q. FT'
TOTAL:
BUILDING FEE
fonhwit comply with such provisions or this permit shalt be deemed cel ed.
CONSTRUCTION LENDING AGENCY DPSE
1 hemby M. that w
hem is a Comction lending egq n,cy fo performance of
the work for which this permit is issued (Sec. JO9], Civ. C.14
yew
SEISMIC HE
ELECTRIC HE
/�
LCm,r'. Name "'""`•••s...
�.
Lmderx Address
,
QTY MECHANICAL PERMIT FEE
PLUMBING FEE
I ccai fy dad I have read tis npplicadon and state that infirostruion in
PERMITISSUANCE
MECIIANICALFEI?
correct. l agree to Comply with all city and county ordinances add state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR AILD TO MECI I.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless to City of Cupertino against
Ilubilitica,judgments, Costs and expenses which may in any way accrue against said City
AIR JANGLING UNIT (TO 10,O0h CFM)
in consequence of the granting of rix Permit.
-
AIR HANDLING UNIT (OVER 10,000 CFM)
Signature of Applican Arontmctor Dam
EXHAUST FOOD(W/DUCn
PAID
If EATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dale ^auipt
Will the applicant or future building occupant store or handle hazardous material
an defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
IDEATING UNIT (OVER 100,000 BTU)
T
Code, Section x71
EI Yen
Ycx ❑ No
VENI'11AT'ION FAN (SING LE RP.SID)
Willthe applicanmrfmus building occupy Bay equip mem ualityc Management
by the Bay Area Air Quality Management
'aricn s ❑ yeir n rn�❑ No
BOILER- COMP(3UP OR IW,tyJ11 RTU)
P �1SJUAN :DATE
{�'
JAN 4 1995
BOILER - COMP (OVER 100,000 BTU)
NEW
NEW RESIDENTIAL MECII. SQ. Fp,
I have rend to hazardous materials requirements under Chapter 6.95 of the
California lleelth& Safety Coda Sections 25505,25533 and 25534. 1 ambothad that
CITY Ur UUrcnIII�
I
if the building does not curen0y have a tenant, that it is my responsibility to notify to
Oc'cupancIt'l t of the reyuiremenk whicM1 moat M1c met priono issuance of a Cenificute of
cy.
BY:TT65
Owner or aathorPzed agent Dote
TOTAL: ISSUED
L)rl-IUL