27281 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO arsti.lu
IN;-ME HA PERMIT NO.
APPLICATION/PERMIT
PLUMB INJECSP:CHANIFICA
BUILDING DIVISION HIIILDINf.PRO.I F.C'i'IUBN'1'IFlCATIfIN 27281
BUILDING ADDR'FF/Mi ( SANITARYNO. APMICA'fIONSUB/MIITTALDATE
�l jr" D`G/O�e-5 UNITY 1.010 � 1 ►_l�^\�
O NHRS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
etc,/L7"g, , D C�CorIL /3— ;Q'$'�/Z lsC COYFROLN
ARCIIITECI'/f!NCINIiIiR: LIC NO'. ADDRESS: ❑ 01
Co Z— — /ZZ TV Sqt f. Svl/ t�
CONTAC^ Co PHONE: BUILDING PERMIT INTO
QTY. ELECTRICPERMIT FEE
7 BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �� jLt�( A. �(LI��Laaaar
LICENSED COM RACI'ORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pXZ I hereby affirm Nm tato licensed under pmvisionsofasipwr9(conunencing with
Y102 Section 70(aPof Division 3 of the Business and Professions Cdcs and my license is in PANELS
sic 1— fail l I meeund effect
FZw
SF0w�-
l
yQy Date Cnnmuma 201-I"AMPS
ZOrN— ARCHITECTS DECLARATIONOVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—M Iundeptand my plans shall be usedaspublicrecon],
P L,t:w SIGNS ELECTRICAL i/e T /
<a47 Licensed Professional ['I J
OWNER-BUILDER DEC tAT[ N SPECIAL CIRCUIT/MISC.
KO W U1 hereby,effrm Nal 1 am exempt fro a Contract es License law for the G.4Q p.D
Wa e o oy hdlnwing auson.(Section 70JL5,Buvi andPoi de:Any city urcounty
TEMP.METER OR POLE INST. O
1 F LLog which¢quires u permit io cerstru ,a ter,improve,demolish or repair any structure
Fnot
Y;7 primmiuisenance,alsorequ' Nempplicentfmauch pertniuo tleeaignd summent POWER DEVICES
W1d00 that he is licensed pars mtheprovisionofthe Coot.mr's 'ease I�w(Chapter
dd 9(contmencin estion7IX10)of DHision3of Ne Biamenan ePmfessiom Cde SWIMMING POOL ELECTJC
%sty ) VALUATION
Wim omhmhei Anyvlolationof
[—Za Sediun703 bymyapplicnnforapermluubjectst licamte, ivilpendtyof OUTLETS-SWITCHES-FIXTURES
j=am nrnmrnethan shundreddo11vs(S500). \ -2-Rel\el
pF13 NEWRSIDENTIALELEI —SQ.FT.spe rt.ormyemploye wit
STORIES TYPECONSRUCTIONagemtheirsolec pereatioo,
I x312 windothework. thesoucrumiinoti n J feandroreaeis .7 .Basins,
and Prnreaninna CCK :The Convactnr's at Law does not'a r of
pmpannywhobuildaor prove rt m , whod¢aaaenwo selforBuougn nix OCC.GROUT' RES.UNITS
employess,pvid that, mmionto dotortd
es eronm frefmaNe.If.
h—ever.thebuBtengor i' m i soldwithinoneyc fcompledon,the owner
-
budder will have the bode o pm g at he did not buor improve for purpose or
QTY. PLGMBINGP IT FEE ILOODZONE APN
❑ Lasuwncrofthm
cppn e
emescluw aivelycingwiNlimnsem
dcomuchma
comemel the Project(Sec.7 ,Business and staimp,Cde:)the p�mmmnrt
License Lawdms not apply to an w ernfpmpe who builds orimprovestherson,arel PERMIT ISSUANCE
who contracts for such limjecu wi a ommc s)licen elpunuantmtheeontraamrs ALTIiR-DRAIN&VF: T- T EA) -
Llcen.mLaw. ( FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this tenon BACK MOW PROTECT.DEV IiOUTSIDE FEI?S
1 A SANITARY Y N
RECEIPI'N
� co WORKMAN COMPENSATION DECLARATION DRAINS FLOOR.ROOF,AREA,COND. SCHOOLTAX Y N
1 hnmby ufhrm that I hove a ttnilicmeol conxm Io self-imus,or a ceni0am of RECEIPT N
FIXTURES-PER TRAP
or4m'Grmpenution lnuranttmvicenified cops thermfl5«.3600,Lab CJ which PARK FEF: Y N
n all ern e,ypdcr thin perrniL RECE1V1'N
PulieyN of 3 w���G�Z GAS�IA.SYSTLM-I INC.40lIrLETS BUILPWr DIVISION Fl-'S
Company
( '% CuniOd cn y is erch f . GAS-EA.SYSTEM"OVER 4 EA) PIANCIE
0 Ceniid tory is fled with the CK PI313 ^VII�a
city inspection division. GREASF/INDUSTRI.WASTE INTERCEPTOR GRADING IEE Y
CERTIFICATE OI'EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE Soil's FEE aa—
(IhisxectionomdnotMcomplelvlirtheparmitisforonehundreddollwa($IM) SEWER-SANITARY-STORM 8A.20BFT. ENERGY IEE \L�
or los.) �CIf7
f I certify that in Nc performvnce ofthe work for which this permit is issued,(shall WATER HEATER W/VENT/ELECI'R
not employ ony person in any mammy so as to becone subject ro the Workcm' PAID
Compenution"w,or California Date WATER SYSTEMflREATING Dale Reccipl
Q z Applicant
z0 NOT ICE TO APPLICANT:If,after making this Cerifase of Exemptions,you should NEW RESIDENTIAL PLMB SQ.FT. TOTAL:
hao becmne s.bjecrm the Worker'.Compe,saint provisions of the Lmir Cede,you moat
a 5 forthwith comply with such provisioru m this permit shall be Jemnd revoked. BUILDING
0. [� CONSTRUCTION LENDING AGENCY SEISMI - E O
U z Ihereby affirm Jut there is a construction lerldingripncy for the performance of
U O the work for which this permit is i...M(Sue.3097,Civ.CJ AMU bt ELI? IC I
Lenders Name PLl1 'G IEE?
Q U Lenders Address QT'Y. MECHANICAL PERMIT' FEE
I senily that I have read Ni,apPlicution and.toe Net Ne abuse infnrmaYon is
correct.I agree,to comply with all city arta county ordinances and mare law,relating to PERMIT ISSUANCIi MECIIA CAL FEI AW
F" building cnmvucrion,and hereby authorize representativesuflhis city to enter upon the CONSTRUCf10 AX
U Zabove-mentiond property for inspection purposes. ALTERORADDTOMECH.
(We)agree to seve,indemnify and keep harsda.the City of Cupertino ag.irel
Iiabilities,judgmenu.costs and expenses which may in any way accrue agalnat said City AIR HANDLING UNIT(TO I0d0D0 CFM)
into sequenccoftbegmni fNiapsn hi
AIR HANDLING UNIT(OVER 110.004)CPM)
Sgneum of ApplmanUCnntmaor pts 17XIIAUST HOOD IW/DUCII
PAID
HA]ARDOUS MATERIALS DISCLOSURE I IHATING UNIT(TO 100,010 BTU) Dam Rcccipl0
Will the applicant or fulure buildinloceelanl smrc or handle hazarbu.material HEATING UNIT(OVER H10,000 BTU) TOTAL:
as def ned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cdc,Section 25332(a)?
❑Ycs ❑No VENTILATION FAN(SINGLE RESID)
\4-(� ISSUANCE DATE
Will the applicant or y the fulumbuildin LIP OR 100, BTU)
100,M)g� nc equipment ordeviceswhishemit BOILER-COMP(
hoodoos air mnmminmts as defined bby the Bay Area Air Quality Management
Distinct? BOILER-COMP(OVER Hkjsi)(1 B'TU) PAID
❑Ycs ❑No NEW RESIDENTIAL MUCH. SQ.Pf.
I have mud the havardous noas,iah re,immenu under Chapter 6A5 of the JUL �� X 995
California Health&Safety Code.Scrtiooa 25505,25533 and 25534.1 indent lardthin
it he huilding does sol currend,bane a tenant,that it is my resMrreibibly in notify the /v'h
occupant of the requirements which must M met prior to Issuance of a certlllctte of V I I
Oceit Crr.
Ownerc,.ail cd agent Date ISSUEDat BY:
OFFICE