27207 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HIL...N�LE,rRI PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING PRO J-MECHANICAL. 27207
i BUILDING PROJRGT'IDENT'IFICA'fIfSN
BUILDING ADDRESS: iCL/�y 1 F /�/ SANITARY NO. PLICATION SI3BMr TE
I�.J �• M UNIT Is LOT# G
OWN `S AMF.: ��„IIO'L4F.: Col,Fe 'OR'$01C (� LIC NO:
G /V'r sW\UL\s_�'1!/r—. NIC CONTROL#
• ARCH1TECf/EN (NEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. EBUILDING PERMIT INFO
ELECTRIC PERMIT FEE FFFLIN QI
FFFJJJX
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
C=z I herebyafftnm that l am licensed undcrprovisima fLTapler9(commencing with
POO SectionT)(lom'Division 3 of the Business and Professions Cade,and my license is in PANELS gIa/�� 1
FjK V full force and-flat. S ` D W L ,
Q flame Class Lic.N UP T0200 AMPS
NW
vai Date Comrector 201-100)AMP5
Z F D ARCHITECTS DECLARATION SQ.FT.FLOG t/SQ.M.
I understand my plans shall be used as public records. OVER 1000 AhBS
Pz—w ^ O
<' 5 SIGNS ELECTRICAL ' / ' 1
Q,YW,'� Licensed Professional L
KOwu OWNER-BUILDERDECLARATIONSPECIAL CIRCUR/MISC.
a0a V I hereby affirm that 1 and exempt from the Connectors License law for the 1 L
following res9on(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
Opermit `0 �
m1 which requires a permit to construct,alter,improve,demolish,or repair my structure
}� prior to its issuance,also requires theapplicaat for such Permit o file a signed statement POWER DEVICES
p0m that he is licensed pursuant to the provisions of the Cmnracmr's License Law(Chapter
Ia.X 0. 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRICorthat /'�1 `_VALUATION _
yxj_y Sectio 703ueby any refrom apheart fshe baspermit sbjeasegedpxempst to civiny l
of OUTLETS-SWITCHES-FIXTURES Iqu
nororm703156y hundredollars($50 permit subjects the applicenuoacivilpenelry of L `
pa, nm more than rive hundred dollars(55110). NEW RESIDEMTALELECIR S
ec�m ❑ Losnwnernftheproany,ormyempinyees withwpg<sas Neinolecompcnsedon, Q STORIES TYPECONSTRUMON
a3— will Jo the work,and the structure isnot intended proffered forrale(Sec.7014,Busineu
and professions Cale:The Couremors Limnse Law does not apply to at owner of
pmpcny who huildsmimpowIs theater,andwhodmssuchwork Mmulfnrtroughhis OCC GROUP RFS.—UNITS
own employees,provided t hat such i mprovemems eat not intended or of fered for sale.If,
however,the building or improvement is sold within one year of cmnpletion,the owner-
builder will have the burden of proving that he did act build or improve for purpose of
❑ I,-towner o(the property,mncaclusivelyconveaingwitlicertsed conwdon to QTY, PLUMBING PERMIT F. F100 ZONE APN
construct the projmt(Sec.7044,Business and Professions Code:)The Contractors PERMIT ISSUANCE /
Lica seLaw Jasnut apply to an ownerofproperty whobuiIdsor improvesthereon,and
whoembacts forsuch projeas with acontmetor(s)licensed pursuant to the Convectors ALTER FA
ARYLicene Low.
❑ 1 am exempt under Sec. ,B&P C for this reason O T SIDE FERS
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date• DRAMS-BOOR.ROOF.ARFA,GOND. RECEIPT#cove WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
C3Ihemffim
byarthat l have accoificloWafconenm self-insurem
,oraniftcateof RECFIP #
Wmixers'Compencestion insurance me mnifed copy therwf(Sec.31300,Lab C.)which FIXTURBS-PERTRAP PARKFEH Y N
n all employee's under this permit GAS-EA.SYSTEM.I INCA OUTLET'S RECEIPT It
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEC 002b aaaaaa`*
❑ Certified copy is hereby furnished.
❑ Cerdfred copy is fled wit the city inspection division. GREASFONDUSTRL WASTE INTFRCEPFOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Mit section need not he completed lithe permit is foram hundred dallan(5100) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
or IE49.)
I ceNfy that in to Performance ofthe work per which this Permit isioucd,I shall WATER HEATER W/VENT/ELr=
not employ any person in any mender so as to became subject to to Workers' PAID
Compensation Lawsof Cdifomis. Data WATER SYSTEMfMEATING Date Receipt Is
Q Z Applicant
z NOTICE TO APPLICANT:If,after meting this Certificate of Exemption,you should NEW RESIDENTIAL.PLMIU SQ.FT. TOTAL:
.I. became Subject to to Worker'-Cumpedumm provisions of to Labor Code,you mus[
> forthwith comply with such provisions or this porton shall he deemed revoked. BUILDING PERIle:
W Z CONSTRUCTION LENDING AGENCY SEISMIC FIDE
5 1 hereby ufftrm tm tem is a concoction lending rgency for to performanu of
the work for which this t is issued(Set.3097,Civ.C.) T T .: ELECTRICFEE
V Poi
Lender's Name
fl. F LcnJcrs Address QTY. MECHANICAL PERMIT hF.E PLUMBING FEEV
;" I cenify that I have mad this application and state that to above information is MECHANICAL FEE Q
4 correct. I agree to comply with all city add county ordinances and state laws teleting to I PERMIT ISSUANCE
�-� to huilding cormuction,and hereby aethodzereprmcntadves ofthis city teener upon the CONSTRUCTION TAX
U Z above-memioned property for inspection purposes.
(We)ague to nave,indemnify and keep harm era to City of Connor..,lost ALTER OR ADD TO MECH. 2 ' b a—
in
ondexpenes which may inany wayaccrueagainst said City AIR HANDLING UNIT TFO 10,000 CFM) alyr
in con. rp mol the grenungof Nisperoul.
AIR HANDLING UT(OVER 10.0110 CFM)
Signature ofAup,licion)(7.1nocrou Data EXHAUS'FHOOD(W/DUCT) PAID
HAZARDOUS h ATF.RIALS DISCLOSURE HEATING UNIT CFO 100,000 BTU) Data Receipt#
Will the applicant or future building mcupmt stem or handle hazardous material ❑EATING UNIT(OVER 100.tN10 BTU) TOT
as defined by the Cupertino Municipal Cade,Chapter 9.12,and to Health and Safety
Cale,Section 25532(a)T
❑Yes ❑No VENTILATION FAN(SINGLH RCSID)
BOILER-COMP(3HP OR]BLOW BTU)
ISSUANCE ATE
Will theapplicaotnrfmurc buildingmcupanmseequipmcm ordevices which emit 1¢'a�' sWAW
hazardous air Imteminanrs as defined by to Bay Area Air Quality Management BOILER-COMP(OVER❑110,010 BTU)
•
Dismiss?
11 Yes 24 1995
Yu ❑No NEW RESIDENTIAL MECII. SQ.FT.
1 have read the hazardous materials requiremems under Chapter 6.95 of the r+//
California Health&Safety Code,Sections 25505.25533 and 25534.I understand that to Vf
if the building does not currently have a tenant,that it is my responsibility to notify to LUf v
mcufa t of mems which must he met prior m iast, qa of a Certificate of
Occupancy /
Owner or authorized agent Data TOT L ISSUED BY:
OFFIC