27812 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,C I RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n pe, n
Ill PROJECT IDEN'TIFICAI DON L O 1 L
BUILDING ADDRESSSL SANITARY NO, APPLICATION/SUBMITTAL DATE
IioIREV UNIT# LOTM ar
OWNERS AME: PHONE: CONTRACTOR'S NAME: LIC NO: "" l
OWNERS
e' N/C CONTROL#
CHI'1IiC'UF GINEER: LICNO: ADDRESS: ❑
C 'ACA: PHONE: "" BUILDING PERMIT INFO
I-i � •//j1i A,L '�)hG q 0 Q QTY, ELECTRIC PERMIT FE6
YY "v r'x�J �1/ TBLDG F PLUMU MECI
PERMIT ISSUANCE _
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RFSIDFMIAL
Ih-reb frtmnhatlamlicertadunder p ( gwitIt ^� TOB DESCRIPTION
C=Z Ya prnvisinnsofCTa ter9 comm<ncin ✓
s
,W UE fall an 70UD)of Division J of the Business and Professions Code,end my license is in PANELS
$
Licertceand-�eet.
Licero
QZ yI e Class Lic.p UP T02W AMPS �
tidy Dae Contmmar 2UI-IIXIO AMPS
ZOrryr z' ARC]II'1'IiCI"S DECLARATION -�S .ILOO�kPA E/SQ.IT.
9yy21
1 male,tand my plans short be cared av public records. OVER 1000 AMPS NN
W SIGNS
�y 6 OWNER-BUILDER DECLARATION SPECIALCRCUI'I'/MISC.
Licenxed l'momwimad .1" LAA
XOitiF I hereby affirm thin I am exempt from the Contmctar's License Ww far the 7���tr�99�
3 t'-m IF
which requiresit permit m roma ,a ter,improve demolish,or re following reason.(Section 7031.5,Husi oressions Cade:Any city or county TEMP.METER OR POI- T.
F a O G t t
y. pair any a me care
prised to its issuance,also re, theapplica lforsuc permit to file a signed statement POWER DEVICES
W C p O thanhe is licensed pursu to the provisions of the C ntmemrs License Law(Chapter
1r<0
Q 9(commencingwit c,hm70W).f Divishba3nfth Busim,licad Professions Code) SWIMMING POOLELC
VALUATION
�s
orthahcisene therefrom anJ the basis for the aIle ed exemption.Any violaion of UTLEfS-SWI9'CHLS-FIXTUR / ���_
F Q, ScI num cal 1. y ary decd olomt rs($50 unit subjms t e epplicem to a civil penalty of (�
nannnre thn Rvc hundred dollars($5110).
� ❑ Lain neroftheproperly,orm em to eeswitliw eseatheirsolecom WRFSIDIiN1'IAI.ELT:CTR .FT,
Y t Y pBusinen, STORIES TYPF.CONSTRUCTION
y3-, will 11 .h ark,Cand, Iheoe maure isnotintendese La it for at apply 1.out Nosiness i1
and„o Prof.sinus 1d,m i The Couvac ar,License Law d snot apply to an owner of l/ .
properly htbuilds orimproves the n,w lwhodoessuc work himselfonhrough his
own m layers,provided thatsuchi f
pr gpRrenatin adedmixfferedforwle.If, GUNITS
OCGROUP RI
howeve thebuildingorimptoveme i dwahinoneye ofecmpletion,theawnal,
builder ill have th but n �thedidrombuil rimproveforpuryomof
sole.).
❑ 1, ownero th umexclusivelyconamet w hlicenudexamaaornm QTY' PLUMBING PERMIT PTE FLOOD ZONE APN
nstns the pro' 7 ,Baines-end Pro cions e:)The Conwaor's
PERMIT ISSUANCE Q� n
License) rwdtasnota I`ymanownerof propcn hobuilds orimprovnCourn mans
whocnm cufor such' ctswith aconwet s)licensed pmmomumhe Cunwetor's ALTER-DRAIN&VENT-WATEk
El I sL w, - (EA) PEE SUMMARY-
❑ 1 tan exempt cauda c. ,B&P C for thin Malan BACK FLOW PRO'I'FCT,DEVICE. .ISI.FEES
SANI'T'ARY Y_N_
OwnerXre,,.,,.
Date DRAINS-FLOOR,ROOF,AREA,COND. RLCFTPT#
KMAN MPFNSA'1'ION UF.ChARATION SCHOOL TAX YN
HM1atll, eacenihcmeofconsemmself-insum,oracerlificuteof RECEIPT.
IXTIJRFS-PER"TRAP
orkcronl umnce nrearlificd ropy thertof(Sev.Jg00.lwb CJ which PARK FEE
cavemder�ispermiv GAS-EA.SYSTEM. INC.4 OUTLETS B �Il pp FEES
rahr
CampaGAS-FA.SYSIEM-OVER4(FA) PLANCHF,
❑ Chereby fumixhed. 9-141❑ CfilN with tM1e city inspection division GREASMNDUSTRL WASTE INTERCEPTOR
GRA `
a^�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAPSOILS E
COMPENSATION INSURANCE
or lcsx.)his section need notharmpletal if the pemrit is for one hundred doll:va($1(X17 SEWER.SANITARY-STORM EA.20UFT. ENERGY FEE L
I certify that in the performance of the work for which this permit is issued,I ahead WATER HEATER W/VBh1T, F.CTR .r
urn emplay any perso n any mummer out re m become subject to the Wisdom' PAID
Cnmpenwtinn Lews of Califomio. Dote WATER SYSITWIRPA9'ING pare /V�Rftn,
O Z Applicant
z 0 NOTICE TO APPLICANT,If.after making this Certificate of Exemption,yaushould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rEA became subjectto the Workers Compensation pmviaions of the Labor Code,you must JV
� , forthwith comply with such provisions or this permit shell be deemed invoked. BUILDINGIEE
w z CONSTRUCTION LENDING AGENCY -
SEISMIC
•F� I hereby affirm d at there is a construction lending.gency for the perfn ams;,of
V O the wood,fol which this permit is issued(Sec.3097,Civ.C.) 9LR C ,E
Lend Nam
� U Isnd .odd ss QTY. �J `:,MECHANICAL PERMIT
1 certify that 1 have read this application and state that the above mfotmauon is
}' a cartect.I agree to comply with all city and county ordinanem and state laws testing to ,PERMIT ISSUANCE M
F” y huiliing construction,and hereby authorize representatives ofthis city menrerupmthe CONSTRU IONTAX
V Z naive mentioned property for inspection purposes. ALTERORADDTOMECIL
(We)agree to save,indemnify and keep hamdess the City of Cupertino against
Iiabilities,judgmems,costs and expenses which may in any wayoueme against said City AIR HANDLING UNIT(1'010,"CFM)
in-nrnsequ-nee of th gmntin this permit.
AIRHANDLING UNIT(OVER ID."CFM)
Sign c-WiflicirmleffIllmot., Dote- EXHAUSTHOOD(WNUCT)
PAID
HAZARDOUS MAI HRIALS DISCLOSURE HEATING UNIT(TO I BOAH)BTU) Date Receipt#
Will the applicant or"am building ocrnpnm score or handle hazardous material
m delisted by the Catarrhal Municipal Code,ChapmT 412,and the Health wd Safety HEATING UNIT(OVER W,tIW BTU)
Crate,Section 25532(m?
❑Yes ❑Nn NTILATION FAN(SINGLE.RESIDE
Willtair concentrations
building by
daseequipmir Quality
Management
OILER-COMP(311P OR IWJOW BTU) ISS NCE DATE
Nous air contaminants a defined by the Bay Arta Air Quality Mnnagcmem
pct" BOILER-COMP(OVER I(IO,IXq RTU)
❑Yes ❑No NEW RESIDENTIAL.MECIf. SQ.IIT,
y 1 have read the hazardous mautials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 255(15,25533 and 25534.1 undemtand that
if than building dues not currently have a ienam,thnl it it my responsibility w nmify the
ccupanl of the requirements which must Mo tact prior to issuance urn Cenificmc of
Occupawy.
Owner or atuhorized agent Data OT ISSUED BY:
op
OFFIC