27205 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILVINt;F' A PERMIT NO. /'' O /�
APPLICATION/PERMIT PLUMBING'MECHANICAL C Vl
BUILDING DIVISION BUILDING PROJECIADENTIFTCATION
BUILDINGAr1DDRESS: 1 ��-�F///����-( ``��/{y\.�� 1/�/k �J SANITARY NO. APPLIOC ONSUBMI ALDATE
2 V \3z ' " VQ'UNIT# 9iW 2373 I
OWNER NAME: PHONE QONTRpQJ7R'$NA ' / LC N/C
I ARCIU CT/ENGINE . LIC NO: DRESS: -J/ F
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
MUCH ELECT PLUMB M
� IQI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL yWWWLf
O C 7 I hereby affirmthat l am licensed underprovisions of Chapter9(commosem,with JOB DESCRIPTION
n 00F Sectio]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
<ut full force and effect. UPT0200AMPS r1C� ���n�1
FZW vys, Chis] Lic.b rJLJ
rn G at' e / One. 201-1000 AMPS
[-y ARCHITF.CTSDECLARATION OVER 1000 AMPS SQ,FT. RAREA S/SQ.FT.
ZO b'? 1 undersand an,plans shall be used in public records.
SIGNS ELECTRICAL
Q,j„�J Licensed Professional
=,d'6 OWNER.BUILDERDECLARATION SPECIALCIRCUIT/MISC. Y)
XOaU I hereby affimt that 1 um exempt from the Conlriti License Law,for the -/1
W3wFi following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
O Q which requires a permit to construct.alter,Improve,demolish,or repair any structure
> prior to its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES
WC<C) that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
0,Xo4 9(commencing with Section 7)00)of Division 3 of he Business and Professions Code) SWIMMING POOL ELECBIC \ VALUATION
,mv, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Section
F-< 703 L5 by aayappmi
licant fora pertsubrupp
jects thelicant toa<ivil penalty of IIJ�ClICC//
not raw tM1an rafbe rodny,lormyem). NEWRESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
pe 1: ❑ Las in=rive
vfmndred dollars
llar ($5(11oyeeswith wagesas theirsolecompensa[ion,
will do the work,andbacracmre is not imeadedmirffered farsale(Sec.7044,Business
and Prnfessimns Code:'Ibe Com scum,License Law docs not apply to an owner of
property whobuilds or improves thereon,and whodmevxuph work himselfordaoughhit
employees,provided mpr such improvementsartnot ear of
mtueercd forsale.If,
OCC.GROUP RES.UNITS
huilder ,wmeavet ng Orden of provinghat he nd out year ofcompletion,meowner-f T
builder will have the burden of proving that M did out build m improve for pttryou of
wlc.).
❑ La.ownerofthe property,emexdusivdy contnding wimlicenxecontnctorsm QTY. PLUMBING PERMIT FEE ILOOD'LONE APN
construct me projwt(Sec.7034.Business and Professions Code:)The Contractor's
License Law distant apply to an canerofproperty whobuildsurimproves thereon,vod PERMIT ISSUANCE
who contours forsuch projects with a contracmr(s)licensed pursuant to me Consortium ALTLR-DRAIN&VPNT-WATER
License Law. (EA) FEE SUMMARY
❑ I um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OU"I SIDE FEES
SANITARY Y N
Owner Date URAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
• WORKMAN COMPENSATIONcatsofDECLARATION SCHOOLTAX Y N
❑ era Cio,mI hereby i on Insurance
orriccaletufcopytheor insum,0r Lab
CJcaichcof FIXTURES-PER TRAP RECEIPT al
Wmkera Ctumpenzahon Insurance lr eccnificd copy thcmrf(Sec.3800.Lab CJ which PARK FIiG Y N
covers all employee's under this Permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy X BUILDING DIVISION Pli
Company GAS-FA.SYSTEM-OVER 4IPA) PLANCHECK Iiji
❑ Cenifted copy is hereby famished.
❑ Certified copy is filed witM1 me city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Cltis section need not i completed ifthe permit is fortune hundred dollars(SHXh SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I cattily that in the pedo..of the work fm which this per mit is issued,IsM)i WATER HEATER W/VENT/ELEM
not employ any/P5�° a manner so u to become fact to the Workers' PAID
ti pensat1o0/2s' min a D e WATER SYSTEM[Ti'TING Date Receipt#
at //
OO NO3'IG O P CAT:if.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMR. SQ.Ff. TO]'At
r become subject to me Worker's Compensation provisions of the Labor Code,you must
�iforthwith comply withsuch provisions or this permit shall be deemed revoked. BUILDING FEE
G Q CONSTRUCTION LENDING AGENCY SEISMIC PEE O
z 1 hereby ruff that them is a construction lending agency for the perfommnce of L: ELECTRIC FRE
V O the work for which this Permit is issued(Sec.3097,Civ.C.)
Lender's Name
[I. F PLUMBING FEE Icndcls Address QTY. MECHANICAL PERMIT FEE
U I versify that I have read this application and sate shut the rubove information is MECHANICAL ILC
Ula nmecl.l agree to comply with all city and county ordinances end state laws relalingm PERMITISSUANCET
F- building construction,and hereby authorize representatives of this city to enterupon the CONSTRUC'HONTAX
V z above-mentioned property fm'mspection prop ort. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rabilaies,judynems.costs andexpensw which may in any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
inamxque a gmp of_th—is permi�t. `
AIR HANDLING UNIT(OVER 10,000 CFM)
igielIture f angConaturnir Date EXHAUST FOOD(W/DUC I
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data Receipt#
Will the applimm or future hulldin,occupant stem or handle haaardout namcnal I(ENI0
MATING UNIT(OV ER II04)BTU)
a.defined by he Cupertino Mnone!,it Gde,Chapter 9.12,and the IIcahn and Safety TOTAL:
Code,Section 25532m)
❑Yes El No VENTILATION FAN(SINCLC RESID)
ISSUANCE DATE
Will meappllcant or future buildingoent,cmt use equipmernordevicet whichmao BOILER-COMP(311P OR 100.000 BTU) a
hM
axzous yr contaminants as definedrea by me Bay AAir Quality ManA
Management BOILER 100c"BTU) P I D
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.lel.
I have read the hazardous materials requia Toms under Chapter 6.95 of the OCT 27 1994
Culilitmia 11,al,b&Safety Cod.,Sections 25505,25533 and 25534. I undersand that
if the building does not currently have a tenant,that it is my responsibility to notify the CI Y Ur (,UrrhI INU
[rzcapar t of the mquiremenu which mol met l bpine m Issuance of a Certificate of
Occupancy.
Owner ser aulhnnzul agent Dale T T ISSUED BY: " 5/>• • '
OFFICE