27983 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO UIF.DINT..EEplu ji AI, PERMIT NO
BUH.DINcDIVISION APPLICATION/PERMIT PLUMBIrvG-MECl' 'I I. �] (�O
BUILDING PROJECT IDENTIFICATION. G J O
BUILDING.AD `� Qf5O' ; £�PI^;E>CT"RINCt PFRslM3�I u YYpCJ•.•`x c-`.,F�1EE
SANITARY NO. APPLICATIONS
UBMII
A
DATE
(O71y
, 4 _S7( CA) /✓LIZ UNIT# LOT If
OWILNSyAHONE: CONTCfORSNTI�� C///
CAc6, yQ . LN/C CONFIRM#
R lTECTIENGINFER: 0 ADS �6 Db/
- N
'ONTACT: PIG NM BUILDING PERMIT INFO
e,4
RLDG ELECT PLUMB MUCH
PERMIT ISSUANCE Til �pF. SCA
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I� IORB'DFSCRIPILIO�N'
pyZ Iherehy afi n that l um licensed underpmvisions ofChupher9 lcommeneingwith
FJO2 Section 7opBof Division 3 mine Business and Professions Code,and my license is in PANELS
_z W full force landas effect.
Zm License Class LiC.M UPT02W AMPS
4,6 y Data Conunmor 201-1000 AMPS
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O Z—p 1 undersand my plans shall Na used as public records.ho1 A it
w SIGNS
ICAL
Q� Q Licensed lfevsional OWNER-BUILDER DECLARATION S ECIAL CCIIRTCUIT/MISC. {/1 V 1.!
LO ped,V I hereby affirm that I am exempt from the Contmctrrts License Lew he ,
W vFi following reason.(Sect ]031.5,Business and Professions Code:Any city or ury TEMP.METER OR POLE INST.
which requires n pemti1 to em ouruct,deer,improve,demolish,or repair any
0111 to i"ama,also thea lieantformch Gofilcasi ad ant POWER DEVICES
prier rcyuims pp pemti gn
W da OO that he is licensed pursuant in the Provisions of the Contractor's License Law(Chapter
L 9(commencin with Section 70W (Division 3 ofthe Business and Professions Cede SW ING POOL ELECTRIC
6wl )o ) ] VALUATION
W=m
or he is exempt therc0om and the basis for the alleged exemption.Any not not S le
ITCHES.FIXTURES 3
Q Sermon II13L5 s.hudrddomrs($50rtnit mbjecta the epplicannn,civil illyd
p not more than five hundred dollars($$W). Nr RESIDENTLV-F.LECTR S .FT,
pw ❑ I,unwnerofthe property,ormyemployecswilh wegesmtheirsolecompeasati Q fORIP_S TYPE CONS'TRUCHON
will do the work,und the stmeturc isnot intended omffered(orad,(Sec.]044,Business wase..r�
and Professions Code:The Contractors License Law Jces not apply to an owner of &V
,m,nywhobuildsmimprovesthereon,and whodatessuch walk himselfor through his
employees,pruviJed that such improvemenmarenor inlendMornffereJ fnreale.If, OCC.GROUP RES.UNITS
however,the brildiri,mimptovement is sold withmmea,cortfcompletion,theowner- TAI 1)
builder will have the burden sf proving that he did not build.,improve for purpose of
sale.). s,t 5.5." .
❑ I.MOw erofthepmp ny amexclusivelyconoacungwiNlicenaedrnnlmciomto QTY. PLUMBING PERMIT y.'.. FEH FLOOD ZONE Al'N
consumer the project(Sec,7844,Business and Professions Code:)The Contractor's
Licenu lawdocs notaEly toaro
nmmsOifpperry whobuildscrimpma
veslecomd PERMI'1'ISSUANCC
who contracts for such projects with acontracter(s)licensed punudnt lathe Contractors
Limns,Lew. ALTER-DRAIN&VENT-WAT12R(EA) FEESUMMARY '
❑ 1 am exempt under Sec. ,B&PC for this reason BACK MOW PROTECT.DEVICE. SANITARY O YTD I N
Owner Dam DRAINS-FLOORROOF,AREA,COND. RI!CIi1F1'N
,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_N
❑ I hereby affirm that l have a cenificate m emssenfto set Ginsurs.or a certificate of RF.CI?IPfil
kWrkers'Cmmpensatimr
n lnstimmus a certifipy ed cothertaf(Sce.3800,Lm CJ which FIXTUNIS-PER TRAP PARK FEE Y N
overs Nl employee's under this permit. GAS-HA.SYSTEM-I INC.4 OUTLETS RLCLIPT 11
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTE2vl4(EA) PLANCHECK EE
❑ Certified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GREASETNDUSTRI.WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE MAP SOILS FEE
COMPENSATION
COMPENSATION INSURANCE
(This sclumnneed notbe completed if Ne permit is forms,hundred do)[.1$100) SEWER-SANITARY-STORM EA.200111'. ENERGY FET! Qa
or less.)
I certify Ead inch,performwce of the work for whichdra permit is iasuad,l shot] WATER HEATER WNENT/ELECTR
not couplay Comlonaro only w.asse*Cdifomia Orsian in my former so s =o� byct to N,Workers' PAID
z applicant
i/Yf/J L WATER SYS'IEM?RIiATING Uate
ZO 0 NOTICE FIT 1 NT:If,afty makingvihis Certificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.FT. TOTAL:
L—I 7) become object to the Workers Compensation provisions of the Labal Code,you..at
LR' forthwith comply with such provisions or Nis permit shall be dictated revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE ;
Vz I hereby affirm that there is a construction lending agency for the performance of
O the work for which this permit is ismed(Sce.3097,Civ.C.) O�A,L: LLF.CfRTCFF.
Landers Name
C) F Lenders Address QTLY, - ,MECHANICAL PERMIT FEE PLUMBING e
U 1 ccnify that 1 have read this application and state that the above mformmu n ' ` '
.�"' a cmrcct. la to cram I With dl cit dcoun cadmium ium and slam lawand in to PERMIT ISSUANCE MECHANICAL :C
Bsce PYwi city rye a
Fi Cn building construction,and hereby authorize rcpresentativesofthiscity toemcrupotnhe CONSTRUCTION' X
U Z move-mentioned property for inspection purpows. ALTER OR ADD TO MECI I.
(We)agree to save,indemnify and keep homeless the City of Ci penia against _�
Iiabilipies,judgments.cwcs and expenses which may many way accrue against said City AIR HANDLING UNIT(TO IL WCFM) st
inc eme�of the granting of this permit.
;%�g�eL AIR HANDLING UNIT(OVER 10.000 CFM)
Sigsatu��AAppppliimaar?7Cumrazt am`l EXHAUST HOOD OVIDUCT '
PAID
HAZARDOUS MATERIALS DISCLOSURE HEA']'[NO UNIT(TO]FLOW BTU) Det, eceiptN
Will the applicant or future building occupant store or handle hazardous mammal IIEA'fING UNIT(OVER 100.030 TO U) TOT L.
as define)by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety
Code,$ecli Cl v�32(n)7 ❑No VENTILATION FAN(SINGER RISID)
O �P+
VI
ISJUe CE DATE
Will the upplicam orfwum g me
huildincupmtusecquipmemmat it BOILER-COMP(3HP OR 100,010 BTU) t
sard:ms dr commensal as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER I W,000 RTU)
Me'? (�(�[
1:1 Yea ❑No NEW RESIDENTIAL MECII. SQ.IT. DEC 20 1995
Ihave mad the normhaus materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 rind 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the laUf LI�III�U y t
occupant of toe requirements which must be ma prior to issuance of a Certifieam of
fhcupmay.
Owner or acthonzed.,at Data ISSUED BY:� r
'OFFICE