27280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO 11 ILl11NG-ELECTNICA L PERMIT NO. 27280
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL,
BUILDING PROJF,C'P I DENPIFICA'I'ION
f BUILDING( �TJADDDRRESS: is SANITARY NO. APPLKWHONSUBMI1TALDATE
2 NG
If D T Q 1 UNII'p LOS 0
OWNERS NAME: PIIONL: CONTRACIDR'S NAME LIC NO: NIC CONNfROL
De/0 2. .4rt)'.� Fir Co 2 Cmc 3 7/2
kClll'1'ECI'/IiNGINISR: LIC NO: ADDRESS: �.O ❑
�•o ! 1L ZED S.til+t ' K-S!�/, - !`A
CII5NIA� Tr-f PHONE:
�pQ O,N/E QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
7TG"'7 �3 BLUSG EOL' PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL LOB DIiSCRIPTION
Mmz I hereby alfrm that l wart Nocnsal under previsions of Chaplcr9(commencing with
WOOF SectionlWE,o Division 3.1 the Beincssond Profesaiom Cade,and my license is in PANELS
Fee V U full force and effect s, i Z
Q�w I,icennc Class Lic.N o s7 UP TO 200 AMPS
H Qy Dam Contractor 201.HNID AMPS SQ.FT.FLOOR AREA SISQ.Ff.
I—ri,,Z ARCHITECTS DECLARATION OVER IOAMPS
o'l0N0 FOIsnderswaimy plum hall heusedaspublicmcoNs. N• �� �\
dna F-J SIGNS ELECTRICAL f,/v{
<Y7� Licensed Pmfeuional L
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyF I hereby affirm ihnl 1 am esen t Imon oto Contractor's License Law for the G e �-7 06 WX 6S
to 3 a to following maven.(Section]031.5.Business and Professions Code Any city or county TEMP.METF,R OR POLE.INST.
which"of.,a .it,.consma ,eheir.improve demolish,or repair any xtmct.m
mwprior ser is issuance.also requires the applicant l'or such permit In file u Signed smtemcnt POWER DEVICES
W Y a Cz that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
daaLL 0(commencing with Scctfon1000)of Division 3 of the Business and Professions Code) SWIMMING POOL RI.ECfRIC I'ION�
_¢
or that he is excnrprtherefiom and the basis for thenlleged uxemploa.Any vinbeionof 3
E 7! Scai00)031.5 by any applicant for•permit subjects She applicant to to a civil Iz.IIy of OUTLETS-S W ITCHGS-FIXTURES 01 LUA VAI1hUA1
N
not mom than five hundred dollars(SSW).
CFo El1.usownernithcprc)vrty,ortnyanployccswilhwegeusthere)lccom,nosed.., NEW kESID13NT1A1.ELECTR SQ.IT, STOR117 '1'YPti CONSTRUCTION
yam wile do work,said the stru<turei.not intended or offered for sale(Sec.104,1.Business
and Profession%Cade:The Contractors License law does not apply to w owner of
II pmpenywyees.dsorimprovcslhcmprrve who Jtwnwcbwmk hirtoelfonM1mugh bis
ownempluy¢S.provideJ thnuuch improvcmenuve not imendedumffeed(orale.If, OCC GROUP RFS.UNITS
however,the building or improvement is sold within one year ofcompletiun,theowner-
builder will have the burden of proving that be did not build or improve for purpose of CIO
sale.).
❑ I,mowneroDne pmpmy,am excluxivelymma6ngwilh licensed connecmnm QTY. PLUMBING PERMIT FEE F1.000'l,UNE APN
msrun the p ten(Sec.7044.Boor—and Pror-n Core)'Ihe Cn araaor'n 1PERMIT ISSUANCE
License Lawdocn not apply man uwnerof property whobuildsorimpmNeuron,eon,and
whoannlrana for such pmjects with acontructor(x)licensed pursuant to the Comractolx
Licione Low. gLTER-DRAIN&VENT- EA) FEE SUMMARY
❑ 1 am exempt tundra Sec. ,B&P C for this reason BACK FLOW PROTECT.DZ 0U 1:SIDE FEF--S
SANITARY Y N
Owner Date DRAIN. -FLOOk.ROOF.ARI3A, ). RECF,IPI'N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby affirm that l love a certificate ofconsentto self-insue.m a certificate of FJDTURIS- TRAP RECEIPT
rtes'Compensation lnsutwceor a rarified cnpyiherem((Seo 3X00,Lab C)which PARK FEI3 Y N
re all cmplu eexunif rdis 'I RECEIPT'
Poli< N >` '. �OOO pG-7L GAS-LA.STSTE INC.40UTLF.'
y BUIL. GDCCI S11—
CnmpxnY— s-�•4a hereby famished. GAS-13A.SYSTEM-OV 4(IiA
Certified copy ) PLANCHECK FE
❑
YL Certified copy is filed withthe city lmpenion division. GRGSRgNDUSTRL WASTE I .RCE R✓ GRADING FEE
CERTHICATE OIr EXEMPT ION FROM WORKERSGREASE TRAP SOILS FEF: ^�
COMPENSATION INSURANCE
or les(hiascaiun need nm be completed ifthe permit is feronc headrest dollen($I WE SEWER-SANITARY-STORM EA.2WFT. GNI3RGY PEE `
I certify the in the P'rformanu ofthe wmk forwhich this permit is issued,lshall WATER HEATER W/VFM/ELECIR
not employ any person in any u
n x e as m m
hecoc Subject 4r the Work. PAID
^opPlpa,^mion Laws of Califamiu.mature,
WAl'ER SYSTENETREATING Date R
O z e N
z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDERTIAL PLMB. SQ.FT,
(- become subject o the Workers Compensation provisions of the Leta Cade,you must
foNrw ith comply with such provisions or this permit shail be deemed evoked. BUILDING FEE —
CW (] C'ONSTRUCT'ION LENDING AGENCY SEISMIC PEE
1 hereby Support that then is construction lending agency for the Isrformance of
U p the work for which this permi t is isaued(Site 301 Civ.C.) .. a, ELP:CfR11C E Ilk
Isndcrs Name
O U Iaodcr'x Add.sx QTY. MECHANICALPERMIT FEE PLU+J�e jam
1 cenify that 1 have read this applicul un and atate That the above infmmalion is MECHA F i
>" L1-I correct lugree¢r comply witM1 all city rand county nrJinanco and xtmc lows rtlatingm PERC V MIT ISSUANCE
I—' y buildingennsned Amend hertbyamhonpupsNsenntivea of thiscitymercerupon the CONSTRUCT TAX
U z ebov(We)coned property for impaction keep hour. ALTER OR ADD TO MLCII.
(Wc)udgmntsave,indemnifyand hie may
ny ayacoCity Of Cupenst s against
liabilitiex,judynems.rouse and expenses which may in any wayaccme against City AIR HANDLING UNIT(TO 10,010 CFM)
c cnceefthc gr gofffik permit.r�yJquIf—f,l AIR HANDLING UNIT(OVER I0,000 CPM)
Signature of Applicant/Contracmr (— Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALSOISCLOSURE HEATING UNIT(TO I00,000 BTU) Date RecciptN
Will the applicant orfuture building occupantstore o,handle hacaltha material
m dabnnl by the Cuperin,,,,o{{{{Municipal Calc.Chapter Y.12,and the Ileahb send Safety IIBAI'INO UNIT(OVER 10().000 DTH) 'IY)'PAL:
Cade,recd❑Yes 2(a)e qNo VENTILATION PAN(SINGLE RESID) \,
P
Will theapplicae
nt Or mBOILER-COME(3HP OR IWOW BTU) ISSIJA- BATE
caupant use equipmeordevices whicM1<mit
dt �rn
t wwt//v defined by the Bay Area Air Quuliiy Manageent BOILER-COMP(OVER IW,(XX)BTU)
JUT{Al
a 5
t uses ❑yea pNo NEW RESIDWIIALMICH. SQ,FP. 1995
I have and the hacrNaus materials requirements under Chapter 6.95 of the " 1 + tC�a U
California Health&Safety Code.Sections 25505$5533 and 25534. 1 understand
Uf Lear
and that tg4.1N
if the building docs not currtndy M1uve a tenant Air is my msponsibiluy to ramify the
cupant of the miEtiomen I whluh d M mel prior a isauanoe of a Ccnifi.a of
O
rune,or authorized agent Dnlc \ ISSUEDBY: _
OFFICE