27599 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
PERMITNO.
CITY OF CUPESIO NO APPLICATION/PERMIT DING PROJECT IDENIJICAL
FIC
BUILDING DIVISION „ BUILDING PROJECT IDENTIFlCATION .
27599
BUILDING ADDRESS: r SANITARY NO. AI'I'LICATIONSUBBMITIALDKM
1 01 Tf e 1 UNIT#
y�N KXMIL PHO COQ^ NAME LIC NO: NIC CONTROL#
A Yti 755a�1 flbvly+ deli' 5191 b
cxr1ECT'!�+a1NPm LIC NO: A KESS: ❑
�y gut S.'S.9J If.),
NTACT: PHONE: 'Ju, Cwov ''15.EBUI�bIFIb PPIthDT,IIJPO�..:S�h-I..":4�VSM1
t'4< ?•-" 'R ' Oe: 1t1:.IS
C3 BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPUAHCES-RESIDENTIAL JOB DESCRIPTION
1yx I hembyem Now
Hiral l am limnadundupmvisiofChapur9(wmmwcingwilh ^
JOO Section 7000)of Division 3 aftha Business;and ProfeWom Code.and my 11.Is In PANELS
Nu fora mad effectr
LieemeaW036 Lia.# ] 1411.1 UPTO200AMPS
i=y peas J_/L_I.Oa
—Con lrwtorh[Qyl!nsn", 201.1000 AMPS SQ.FT. R S/SQ.FT.
y ARCHTE(.'1'S DECLARATION OVER Halt AMPS
.� I undersuM my plans"I be used as Public rtsoW.
jt SIGNS ELECTRICAL
Licensed ProfessioW
OWNER-BUTUDER DECLARATION SPECIAL CBRCUrDMISC.
1 U ,- I hereby affirm teat 1 am eanmpt freer,the Contmm/s Lineae Law fee dee
y followiry resume.(Session 70313,Business mm Pmfeuiam Cade:My city arearmry TEMP`MCMI OR POLE INST.
c y which requires a Paws m com-14 alar.Improve,denwBN,or repab my ummtum
Ii j pia in In kuueroe,am require dee applirsn for such permit in fib,a sivocal m POWER DEVICES
'<p telmhuamed pumummdee pwvitiom of theCwuectol.Limas law(sups
cGy. SWB.JMB40 POOL ELECTRIC VALUATION
Y. 9(mnmwoeing with Section]000)or DJvbion 3.f Ne Bud.and Prefectures Code)
j'4�'y atlutMueaemptMcfwm atm deebWs(a deeWryed uanptoo.MYvioWimd _.
Y Session 7031.3 by my applicant fon a permit subiects the Whemtaacivil Penalty of OVILEfS-SWTCFWS-FMTURES
pnee mese tun five hurmd MI.($.500).
NEW RESIDENMLELELTR ps, Sq.FT. STORIES TYPE CONSTRUCTION i
❑ Lao ofdeeprop ty.mmymVloyenwidewrynsslhebwkcempenvtiml.
will dmtonwash.erathe he Contracts U moffered mrseek l,to an Bueiaau
CIM Profwh obu Code:The.s uwr'u Lianss law dcot on apply lf m owns d
popnywmbtldeaimpovwdicmon,and wmdonwch work NmselfaNryghhk OCC GROUP RES.UNITS
owvemployw,provideddeauuchimpovvmnueinnminandedeoffaedfeWe.V,
hove'vee,tSebuildingnimpmvemenrusoldwi noceyurofimprovedon•Meower- TQT
'
builderill ave ton bumw ofpwving tut he did nim mildaimpovc for pupae of _
We.).
❑ Luoe rojecs'Pro.7W. eziness and
PWiesiions,Cucemedcmnxtmm y n.A14iP p SSA�+SM.m FLOOD APN
meamrn the pmlect(Sec JM4,Business CIM Pwlacbmk Code:)The ConustLieand PERMIT ISSUANCE / .D
.benmtswaouucapplrmanawnermfpwprry wermalP o ,cotndeesomme.
_
.be contacts;rasurhpoiecuwim.e000acmA.)Ilomvd pmvuntmthe Conoecmla
Licmm Vw. .. ALTER-DRAW kVENT-WATER
( �• F88,SUMMAR s
❑ Iammimpurma Seo. ',Bd:PCfathi.mown HACK FLAW PROTECT.DEVICE
SANITARY Y N
• .. a Ova DRAINS•FLOOR,ROOP.AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
t ❑t.'t6veby sMvm des thavea�weofconsmtm Wf-:....,...,maentifimeaf RECEIPTN
Wark.W Cemp�mg%ut�im lmmm.�a^s�o'mified copy thereof(Sec.3800,Lab C.)which FIXTIIRF3 PER TRAP .t PARK FEE Y N
Po�Piry�l� •• •' eP�`— SCI(,1 / GAS-EA.SYSTEM-1 WC.4 otn3-ETS OV BUIDINGDB NFEW
I y 9 QR_r'L Lid. _ GAS-EA.SYSTEM-OVER 4(EA) PLV4CIWCK FEE
Cntlfied copy is hemby furnished.
Cmifum copy is Fled wide th dry impection division GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CRTO'TCATEOFIDDEMPTION FROM WORKERS' GREASE TRAPSOILS FFE
COMPENSATION INSURANCE
obbonstionneed lmtbemmdeted ifdeepmtt is formehun &llam(5100) SEWER.SANITARY-STORM EA.MPT. ENERGY FEB
or leu.)
I mvfytw in dee pRemmce of tlo woh for wbich thispeMtulssuM,IshW WATER HEATER W/VCNT/ELECTit _
am employ my p.k my manna w u to became subject to the Wasters PAW
Z Campvuatmlaw.acamared. Dam WATER SYSfEM/IRFATWG Reoeipl#
Applicant
0' NOTICE TO APPLiCANT:If.ahw making dd,Certificate of Exemption,you s!oadd NEW RESIDENTIAL PI-MB. SQ.PT. TOTAL:
y beconm abject m the Workers Compensation moririmu of dee Labor Cmde.you meat
forthwith t
with comply wide such provisions is Amer andl m dceredninvoked. BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herebyeffinn tut there J.acmmwmimn lending agency for to peall ceof
1 O TOTAL: ELECTRIC FEE
1 Ne work far which this permit is luued(Sec.309],Civ.CJ
leader.Nems 'v!t: '•x<._ '�}.h .YlOep •�U
IsMd.Aden. (yry F�CIiANICAI.�PHRM[I`���:'}��,p�;, .e PLt!hmWG FEE
j i wuv^m..n2.vrsaml.::,...rat'rt�5$µ
Lrl 1 certify tat 1 have reed Ws application and sate That me save information k MECHANICAL FEE
cmldingcect. mcdm,pdhmb lnd od mu m%immessi&6ty.kwrvl nm a PERMITISSUANCE
buildingcomvvction,mdherrr ins,a hodmrtparnutivw of dela riry menterupon Ne CONSTRUCTION TAX
1z amv(We)agree property inspection keep
ALTER OR ADO TO MECH.
(We)agree m Live,indemnify era kap
IiaMlitiw,judgmrns,coslamddee City of Cupertino rym
eapmw which mayinaywayernagairmtuid
eery AI0.HANDLING UNIT(T010,000 CFM)
in consequence of dee grating of this pmtl
AIR HANDLING UNIT(OVER 10,000 CFM)
Signatumof AppliwnUConsacwr Dam EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO I W.000 BTU) Date Reecip#
Will the the CuNmctual r Mu busking occupant
t,Chsp mm or handle and
Incautious Safety HEA`TNG UNIT(OVER I W.000 BTU) TOTAL: 36'
u deuced io the 32(it? o Municipal Cods,Chapin 9.12,and dee Health and Sefery
Cada Sermon 25533(q?
❑Ye. 0 N VENTILATION FAN(SING LE 0.ESID7 1
ISSUANCE DATE
Will theapplicanlorfummbuildingacupmwmequipmem ordevicn which emit BOILER-COW(3HP OR 100.000 BTU) T,
herd-a air cw1ainumares u defined by dee Bey Arca Air Quuiry Management BOILER.COW(OVER 1M.000BTJ) A D D
D'smn?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hawdous mnedms eNuiinmms under
lChapteroN
JAN 41995
CaliforniaHealth&Safety Code,Sectios 25505.25533 and 233M.1 understand that
ifie building dresnm cu Pyhveumtealitismywe tooo
acupmtorNemquimnrn which con prior to issuanco .C ificin¢
of GI 1 r-Vf V V TCR 1 IIVV
Oma L
Owner ora egrmData TOTAL: ISSUED BY:
OFFICE