27003 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO •' '• PERM11 NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECUANiCAL OOsJ
:. BUILDING PROJECTIDENTIRCATION ','
BUILDING ADDRESS:�aa `..T` SANITARY NO. A/PPPLIG1��,TIOtttN���SUBMITTAL DATE
221e� I UNI'I'a LOT
OW' E 5 E CONTR R'S NAME LIC NO: r s ` ♦♦l
IELNIC CONTROLN
�IARCHITECT/ENGINEER: LIC NO: V ADDRESS:
CONTACT: PHONE: v.+r
�y4i.HaBUILDING PERMIT INFOELECRCPBRMrt
ter: Zf PEB
ew.."2SGw?'... m;u:.nlyfa:B=X:N.`..'±� +i. �b..J•-+^x{Tv!. BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PPLIANCES-RESIDENTIAL
_yZ IherebY affirm Nmlemlicenaed undernderropvisionxofChepmr9(wmmencingwith TOB DESCRIPTION
0 Section]OBp)ofDivixion7 of the Business and Professions Code,and in,license is in PANELS
CZF fullfortand force and
< W LicensenLicenseCLiag UP T020DAMPS VYVv7 V��"f/1WT]As�.
y<y Dam Contractor 201-IBM AMPS
-�Z ARCHITECrS DECLARATION OVER I"AMPS SQ.F7'.FLOOR AREA $/SQ.PT.
i Z I understand on,plans mull be used a public records.
w F u SIGNS FT ECfRICAL
>!f J Licensed Profeuimal
-Wx< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
.0�V 1 hereby affirm that 1 am exempt from d:Convectors Lt..Law for the
=3 a y following reewn.(Section 7031.5,Business and Pmfeulons Cade:My city or Coumy TEMP.METER OR POLE INST,
Ow 5 which rtquves a pemtit to muwm,other.improve,demolish,or repair any structure POWER DEVICES
}� prior to in issuance.alto requires Ne applicant for such permit mfile•signed Consonant
cot<<O tut he is licensed pmsuanl to the Provisions of the Contracm/s U.law(Chapter SWIMMING POOL ELECTRIC VALUATION
-do fe 9(commencingwith Sedon]OWlof Division3 o(the liminess end Professions Cade)
U,w or slut he is exempt therefrom and Ne haisfor the alleged exemption.Any violuim of
F ZY Sam.7031.5 by any applicant for a penis mbjmu the applimnttoanvil pvWry of OU'l=I-SWITCHES-FIXTURES
< n rc dun five hundred dollars(5500).
CFp owrerofthe Poperry.ormYemploYaawith wagnathhcirwlecompmution, NEWRFSIDENTTALELECfR _SQ.FT. STORIES TYPECONSTRUCI'ION
.3= Ildored.Codd:swmuremnminrmdssm Lawrcdfon apply
in an owner of
Rty who
Cade:The Convector's License law dos not hins lf rt owner is
propcnywhobuilrovi impmvesthemon,and whadOnsuch amkhimmlfon for We.
OCC.GROUP RFS.UNITS
heven owemployes,provided But,such improvements are Use
imeodedoroffered theale.If.
however,illfluhave
teb den of proem is ed he within me yes ofwprove for
she owns-
milder will have Ne burden Of proving Inst he did not build or improve for puryau of
&Y'.
LUNMI.:r..rERM1. s5�.'',II,,,,a, e r
❑ La ownerofthe property,unexclusively Connecting with licensed compactors to Q k�jPLU1kJBING PF.RMIT�f„.,y.0-.sx 4� FEE�"o�cet` FLOOD TONE MN
ceeswm she pmjat(Sec.]OCG.Bniness and Profess ar,Code:)The Contractors 1-
LicwaLawdwsnmapplytowownero(Mro nywhoNildsmimpmvu Nertm,and PERMTT ISSUANCE
whocentmctsfmsuchprejects with acono-amr(s)licensed pws artrotnc Contramon's ,V; ,n y
License law. ALTER-DRAIN&VENT-WATER(EA7 S;vg{i`p�'t;• ,- ;FEE SUMMARY..;_.�_.�,'•,', :r:
❑ I em exempt urMer Sec. ,B&P C for this rcawn BACK FLOW PROTECT.DEVICE ID
qPAIRK
NITARY Y N
Owner Da.— DRAMS-FLOOR ROOF.AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION HOOL TAX Y N
�' ❑ Thereby affirm thatlhave acenifiweofconsmtwmlGinsurt.orece mweof FlXTVRES-PER'IRAP RECEIPI'N
Wmkeri Coe crura on Insurance me ccrdfied copy Nermf(Sa.3500,Lab C.)which FEE Y N
covers all employees under this permit. GAS-EA.SYSTEM-I INC.G OLI77.Ef5 RECEIPT'N
Policy M BUILDING DIVISION FEES
Company GAS.FA.SYSTEM-OVERG(EA) ANCHECK FEE
❑ Cmifiedeopyisnetebymm;alim
❑ Cadfied ropy is filed with the city inspection division. GRFASFANDUSTRL WASTE INTERCEPTOR ADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP ILS FEE
COMPENSATION INSURANCE
(This action rued not becompletd if Ne pmmitie forom hundred dollars(SIM) SEWER-SANITARY-STORM EA.100FT. ENERGY FEE
on lea.)
I certify Nut in the performance of the work for which Nis permit is issued,Imall WATER HEATER W/VENT/E'LBCR.
no,copmy any person many manner w as to become wb*i In Ne Worl PAID
,Z Compenation laws of Califomie. Dam WATER SYSTEM/IRFATING Done Receipt N
Applicant
Z 0 NOTICE TO APPLICANT:II after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Cl� becoreciuijeitto to,Waher's Contimemon provisions,of Ne labor Code,you must
Y 7
forthwith Comply with such provisions or thus permit shill be drnnd mveked. BUILDING FEE
1 Q CONSTRUCTIONLENDINGAGENCY SEISMIC FEE O
J
I hereby affirm that then is a wnstruc,im lending agency for the pcdommia of
O
the doh for which Nie parrot is tossed(sec 3091.Civ.C.) ELECTRIC ME
lender's N. i:.:«,vrv'sa.c.. ;r
QTY bF• .S.;MCHANICAI:PERMIT.'- r',':PEE.r,'.s: -UMewc FEE
lenderi Addoul
}; •.:x:.a -a e.rv._N•.v. 'R'Y MECHANICAL FEE
1 ttnify tut 1 have cud Nis appliaion and sum that the above infowaum is
�•' a coren.Ieg.to Comply with all city and county ordinantts and son:laws:lad.,to PERMITISSUAN
Wilding construction,and hereby au anise representatives of Nis city tomerupon the CONSTRUCTION TAX
J Z above-mentioned propeny for inspection purposes. ALTER O 1)TO MECH.
Me)agree to ave,indemnify and keep harmless the City of Cupmiw agaimt
ludelities,judgmmu,coses andexpenserwhich may in my wayacerue against saidCity A ANDLING UNIT(TO IEM0
in consequence of the grand,of this permit.
AIR HANDLING UNIT(OVER I0.000C RI
Si,,mumof APPlicanVConmacmr m EXHAUST H UCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNI 00.000 Dam RecetPir
Will the applicant m future building accupam tom or handle harardouam of H N (OV N TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safct
Coda Section 25532(O7
❑Yes ❑No VISW61,1 F IN E RESID
ISSUANCE DATE
Will Neapplicanwrfuturebtilding occupant umequipmeumu&,vcnwhichemlt OILER OMP HP OR 100. BTU)
'y Issummus ab comaminanu v defined by Ne Bey Arte Air Qu J Mensgcmcm B -COMP(OVFJi ,ODO BN)
District? " �;
❑Yu ❑No NE IDENTI CH. SQ.FT.
Ir
1 have reed the hazardous mrequirements irSEP 14 ements under Chapter 6.95 of the
4G199
California Health&Safety Code.Sections 25505, and 53,4 l understand that
if the buildingdines not iul,have.,Co.,,that it is responsibility..
sponsibiliry notify the h
«wpm,of the requirements which must he mer pdor w issuanceof•Cenifhn,e of4,
IX Owner
or a. ��I ry
Owner or emhOriud agent Dae TOTAL: ISSUED BY:\`'IS/✓slS/'i
OFFICE