27870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - -BUILDING-ELFU I RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT27870
PLUMBING-MECHANICAL
BUILDINGPROJECT IDENTIFICATION -
RUILDINGA,DIµ-DREyISx$S�.:�•ffynnn/�//t�'p•Dy/Y///} SANITARY NO. APPLICATION SUBMITTAL DATE
'U 21 sAaTm'- ' UNIT# LOT# vs
-
OW ;R NAME; {oav 46 PHO E, —O36�CONTR�T R'Sp NAME;�rfn LIC NO: N/C CONTROL#
•ARCHITECT//ENGINEFR: LIC NO; ADDRESS:\l\#.t110�/\�✓. [�5� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLU ME CH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ihweb [firm OatlamllcensW undo IV nsefCM1at 9 gent JOB DHSCRIPI'ION
P4 C'z Y a prey s o p e and
mmedain Ih
00 Swdod]000) fl rlvieion3 of the Business and Professions Code,unJ my license is in PANELS 1 -
full force and eRul. UP TO 2M AMPS W
F�0.1 License Class Lia# _
m<y Dare Contractor- 201-1000 AMPS
Z FO N,4, ARCHITECTS DECLARATION OVER 1000 AMPS SQ,FT.FLOOR AR LA $/SQ.FE
O'Z"Q 1 understand my plans shall ho used as public records. _
W SIGNS ELECTRICAL
st Licensed Pnifessional
EW OWNER-BUILDER DECLARATION SPECIAL CIRCUFLNIISC.
i hereby affirm that 1 am exempt from the Contractor's License Law for the
o" following reason.(ScOma O3LS,Business and Prnfesvinns Cade:Any city masonry TEMP,METER OR POLE INET.
aJ O d which momma a portnh to conswet,suer,improve,demolish,or repel,any structure -
`Zi- prior tells issuxnca,also re thea lienor l'orsuch uo fileasi edmmemeat POWER DEVICES
qin the
PP Fermi gn
W CO thatmhe isncing wpursuanttothe)of Divisiions of theContractor Business
Licand Pro Lawns Code)
L os, 9(commeis(commencingwith Section7000) Division the
the end exem and.AnyvionsCWe) SWIMMING POOL ELECT RIC VALUATION
' ZZ SectoM1.isexbyanapplicndpt liusurman t the permit
subject thedpplica ion.Anyviolationfradit,of OLD LEIS-SWITCHES-FIXTURES
FZ�' Scwion]d-i LS by wy¢ppliwm fora pennil subjwts theappllcwtto acivll penahy of
Sp of mmthan BvehuWrW dollwn(5500). NEW RESIDENTIALELECTR —SQ.FI'.
W I_'� erandtpropertyre knot
tmpleyed ororwage,ustheirs a.compensation, STORIES 'TYPE CONSTRUCTION
L scallion work,anJ[heslructureisnotintended oreffereJ forralle hots yA(an Business
scallion a ns Cafe:The Comnrefor n who Lewd not apply r of
propertywyers,provided
roves that such improvements
eltwwkhlmselfo nk OldIs
own employees,provided tum such improvements not innndedoroffereJ ,sale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold w in one year ofeompleliondh owner- TOTAL:
builder will have the burden ofproving th ,didematimhdorimproveforpd oeof
sale.).
❑ I,as owner of Ole property exclusively contracting with licensed cdntact ani QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct die project($e- 4,Business and Professions Code-)no Contmc,r'a
License Law does ply loan awarcrafroperty who builds or Improves thereon.' d PERMIT ISSUANCE
wheoimtmc arsuch packets with a indications)licensed pursuant to the Cnntraeto'sALTER-DRAIN&VENT-WATP.R(HA)
License L.t . FEE SUMMARY
❑ 1 am sculpt under Sec, B&P C for this reason BACK PLOW PR09'ECT.DEVICE OUTSIDE. HES
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COartit O ECU RATION SC1100L'IAX Y N
❑ Thereby consa lhutlhnvea certif . nsedlcasol[-insure,orucw a f RECEIPT[#
FIXTURES-PER TRAP
ideasWcarks'Com eyer's rude
umn dcopy thereof(S gLa�i CJ whi PARK FEE Y N
colics attempt yea's anis hist do GAS-EA.SYSTEM-1 INC.4 OUTLETS RF,C
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
1:1 Certified c y is hereby'u 'shed.
❑ Certified c y is filed wi t city iuspe can ivisimu GREASIVINDUSTRL WASTE.INTERCEPTOR GRADING FEE
C TIFICATF,OFEX1IFTIONFROM WORKERSGREASE THAT SOILS THE
COMPENSATION INSURANCE
CTmisswnfth
en d not be completed ie permit is far one dreddollars($100) SEWER-SANITARY-STORM EA,200F1, ENERGY FEE
Or leuJ
icenifythat r perfennanceoftheworkforwhic ispertnllbiimW,Isball WATER HEATER W/VENT/ELPLTR
or amploy any pars n any manner so as to It bieti m Wo Workers' PAID
Compecathim Law,,,,,f afford.. Date / oma su WATER SYSTEM(FREATING Dale Receipt#
O C) Applicant
Z _, NOTICE TO APPLICAN :If,after mold9 is Certificate of Exemption,yon should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
GO bersme,ubjeir mind Wor T'eContra5tionp-rovisions oflhe Labor Code,you most
forthwith comply with such nvild den this permit small be deemed marked. BUILDING PEE
w A CONSTRUCTION LANDING AGENCY SEISMIC FEE -
z I hereby affirm that hem is a construction lending agency for the performance of
U C the work for which this pemtlds issued(See.3097,Civ.C.) L: ELECTRIC PEE
Lenders Name
U Lenders Addres QTY. MECHANICAL PERMIT FEE ; PLUMBING FEE
]a .11 have read this application and stale that the above Information is
�^ correct. logical comply with all cit MECHANICAL FEE
g, ompywi city county ordinuncefthmed state laws PERMIT ISSUANCE
pj buildin .on,nuei n,and M1ereby vu hoameapresw[mmes of thio clry memw upon the
above-m tinned ropmyfer inspI lion purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(W ag to sole,indebea f and keep ImrtNess the City of Cupertino against
bilines 'a meets,costs9nJ exp s,which may inn way accrue ag st said Ci AIR HANDLING UNIT(TO 10,000 CFM)
f h ra oft Be 'c
c..a AIR HANDLING UNIT(OVER 10,000 CPM)
uguawre a ommcto sD a EXHAUST HOOD(WMUCIy
PAID
c HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receip(#
Will the applicant or fare,,building occupatn mora or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 0.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) T
Cade,Section 25532(x)]
❑Yes El No VENTILATION PAN(SINGLE RESID)
Will the¢ liwm ortolan buildin ruse, BOILER-COME(3HP OR 100,000 BTU) ISSUANCE DATE
pp goccupan quipm<nmWeviceswhich emit
• hazardous air contaminants as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU) .
District^ A Q
Lbuiloing
Yes ❑No NEW RESIDENTIAL MECH. SQ.Ff.
rani the hazardous materials roquiremems under Chapter 695 of the WAR `�' 199ealth&Safety Code,Sections 25505,25533 and 25534.1 understand thatng does nm currently have a tenant.Thal it is my responsibility to notify the the requirements which must bo mel prior le issuance of a Certificate of
rUPEHIINO
thorized agent Date TOTAL: ISSUED BY:7r
OFFIC