27538APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING -MECHANICAL
PERMIT NO.
Q+.PPLICATION/PERMIT T'I
BUILDING DIVISION BUILDING PROJECT IDRNTIFICAON
27538
BUILDING ADDRESS:
SANITARYIN
APPLICATION SSU�BMIIITAL DA11
UNIT* —' LOT*
OW ' SNAMF:' PHO
CO CI'OR'S NAM LICN
N/C
❑
CONTROL p
O
/ G ! ^- /
r 5;d
ARCHITECT/ENGINEER: LIC NO:
AggRySS % — ^
'LLl7T
coNTncD PHONE:
(,i',
QTTYJ'[ ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
HO ELECTPLUMB MF"❑CII
rL
�/{{
_5)1,1), 2? ���^' UV
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
1 hemby affirm that I sm licena d under,mvisime ofat,der9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Scaion ]UW) of Ui J m the Business and Tessio Code, and my li,cnx is in
PANELS
I
License Clusr[. Jl'�7lAintr Y
UP T02W AMPS
Dam Comnnor
\
201 - 1000 AMT'S
ARCIII'TECTS DECLARATION
1 understand my plana shall be used as public records.
00
OVER 10AMPS
SQ. FT. MOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Profnaional
SPECIAL CIRCUIi'/MISC.
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 an exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST.
following reason. (S.ion]0315, Bremer and Professions Code: Any city.,county
which nape. a permit m conavuct, site,, improve, demolish, or Orion city mmnaure
prior to its issuance, also requires the applicant for such permit to file a signed statement
POWER DEVICES
O
that he is licensed pursuanuo the provisions of the CmInin .1, License Law (Chapter
9(commencing with Section 7")of Division 3 ofthe Business and professions Cede)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7031.4ypy any applicant for a pe.it subjects the aPDlicwno a civil penaly of
SWIMMING POOL ELECTRIC
VALUATION
OUTLETS - SWITCHES - FIXTURES
or mom thenNvc hundred dollars (E500).
NEW RESIDENTIAL ELECIR _ SQ. FI.
❑ I,asownerofthc property,ormyemployedoroferegeaaside(Ses. compensation.
STORIES
TYPE CONSTRUCTION
will dothe work, and the ahc ofwd f
ontianorintendede toaa,Business
and Professions Code: The Connracmr'a hittnu Law Jces nor apply to an owner of
not
property who builds m impusves rhmera and who du,-a,h work himself or through his
own employees, provided Nonsuch improvements are not intended oroffered Ersale.If,
OCC. GROUP
RFS. UNITS
bowcver, the buddingor improvemem is sol] within one yearofeempletion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as.wncronne propeny.ameadusivery<Onvaning with licensed contractors to
FLOOD ZONE
APN
TOTAL:
QTY. PLUMBING PERMIT FEE
the project (Sec. 701a, Business and Professions Code.) The Contractors
r
Linstruct
icense) -me does na apply", no owner.fprnpcny whobmldsmimproves tM1ereon.end
whocontnes for such Projects with aeontncto s) licensed nutation to the Contractors
Liccnx law.
❑ I am exempt under Sec , B & P C fm Chia reason
PERMITISSUANCE
ALTER - DRAIN &VENT-WAT' LA)
FEE SUMMARY
PACK FLOW PROTECT. U
OUT SIDE FEES
SANITARY Y N
Owner Dare
DRAINS- FLOOR, ROD, AREA, COND.
RF,CEIPT*
WORKMAN COMPENSATION DECLARATION
❑ Thereby off irm rhmlhaveucenifenm of conxnuo ulf-ittsurt, orattrrficam of
Wohesi Compensaion lnsuruncc oranenired copy thermf(Sec. JNOp. Lab CJ which
rialcove yQ '. nJcr h./i
7
SCHOOLTAX YN
RECEIPT*
R%TURES-PERI' P
PARK FEE Y N
0 RECEIPfp
GAS-EA.SY --IINC.40UT1.Ef5
BUILDING DIVISION FEES
Company
❑ Cern ¢s y y Wish I.
❑ Ccnified ropy is fled9yiBr the city inspection division.
GAS- .SYSTEM-OVER4 EA)
PLANCHECK FEE
REASEIINDUSTRL WASTE INTERCEPTOR
GRADIN A-E
C17RTTFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
(Thin section need not be complied ifthe Permit is for one hundred d lafs(SIM)
or less.)
SEWER - SANITARY -, RM EA, 20pFI'.
ENERGY FEE
I certify than in rheperfnonance ofnhe work for which this permit is i ueLlshall
ned employ any person in any manner so as to become subject to i Workers'
Cnmpcnsmionlawsof Califomia. Dam
APplieu r
( ATERIf /F.LE
PAID
Dam Rcceipn*
WA TGR SYS REATING 10
NOTICETOAPPLICANT:ILafmrmakingthis Ccrtificateof Exemption, -should
becomes.bjw to the Workers Compcnsctinn provisions of the Lubar Code, a mus,
forthwith comply with such Provisions Or this Permit shall b, deeed revoke . u
m
NEW IALP IL ,Q
TOTAL:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
1 hemby -from Nat 'here is a emismtction lending agencyth
for e Porto a of
Ne work for which this Pcrgt is issued(See 3097, Civ. C.)
finders Name
SEISMIC FEE
TOTAL:
ELECTRIC FEE
Lenders Address
I anify that 1 have read this application soil slide the 0e oboe, inborn .ion is
QTY. MECHANIC PERMIT FEE
PLUMBING FEF,
PERMIT ISSUANCE
MECHANICAL FRE
rtcct. lagrce to comply with all city and county ordinances and ram laws rela'ng no
building construction, and hereby autbo,ix, reprexnntives ofrhis city to enter a the
above-memiuned nropeny for inspection purposes.
(We) agree In save, indemnify and keep harmless the City of Cupertino aga sl
liubillties,judgme ts.cuss andexpe xs which may in any va,.cmengain,t,.id Ct
in pm:xoty�ncc. fihc a ting of thio ,. /
ALTER OIU OMECIL
CONSTRUCTIONTAX
AIRHAND G UNIT (TO IggO CFM)
AIR H DUNG UNIT (OVER I0.000 CFM)°
��tm��
`sgion eo/I/le ppp carni onvacror T Date
F IAUST HOOD(W/DUCp
!
PAID
HEATING UNI I'(TO IOO,WO PTU)
HAZARDOUS MATERIALS
antsomLOSURE
Will the applicant a foam building occupant stow or handle hazardous material
Date Receipt*
TOTAL:
as define] by the Cupertino Municipal Cod,, Chapter 9.12, and drc Health and Safety
Coda, Section 25532(0)]
HEATING UNIT (OVER Igl,0*0 RTU)
VENTILATION FAN (SINGLE RESID)
1:1 Ye, EI No
Will hc applicamafuwrc building«cupanmxequipmcnmrdeviceawhichemit
BOILER - COMP QHPOR 100,000 BTU)
ISSUANCE DA E
fastidious air comardinams us defined by the Bay Arca Air Quality Management
Uistricn]
BOILER - COMP(OVER 100,000 BTU)
❑ Yes ❑ No
FT,
I have read the hasadow mmetiuls requirements under Chapter 6.9 f rhe
Califomia Health & Safety Code Sections 25505, 255]3 and 25534. I undo d that
FEB 16 1995
if the building does not currently hove a tenant, that in is my responsibility, n tify the
mcupani of Ne requirements which must be ma prior issuance of a Cern nese of
Occupaney.
Lel I i V r' v r
RY:
7NEW�IDENGEl_.
Ownc, cr aurhom ul atom Dute
TAL:ISSUGD
OFFICE