27531 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
IFfi-:LECTRTCA. PERMIT NO.
BUILDING DIVISION CITY OF CUPESIO N NO APPLICATION/PERMIT PLUMtlIN'1JECT:-MECHANICAL 27531
BUILDING PROIDENTIFICATION
BUILDINGGAAAD�DR(ESS: T SANITARY NO. APPIICATIONSUBMIITALDATH
V fC6\ e- UNIT# LOT# Z A
OWNER NAME: PHONE: CONTRAMR�'S NAME, L f�
till �\�✓ �T!' '1/L NIC CONTROL x
RCHITECI'/FINGINFJiR: LIC NO: ADDRESS:
�S b' 1t. ( -r-derA " ❑
CONTACT: PHONE
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
ntO 1
PERMIT LSSUANCE
LICENSEDthautICON'IRACfOR lmonC.ARATI9( pppLTgNCPS-RESIDENTIAL ��f B DF.#('p{�JOjJ_ �
pecZ 11erNryaR Bwlunlianad under povlsions o aper9(c nog wish \V/�F�Y^/O�/1
�u00 Section 7001)of Division 3 of de Bu.:»...b Profinei Cada, yliccmeialn PANELS
WF full fucc endcffal.
F,ZW varve Ch. Lic.0 T0300 AMPS
w?y Dmc_C.. 20 1000Af.1PS
Z FOy7� ARC]HTECPS DECLARATION O � � SQ.FT FLOOR AREA S/SQ.PT.
OZ—® ImMcnund my plmv aM1ell 6c usd.public rccoN
QY�� I�amaed Pmfe.imwl SIGNS CAL
OWNIR.BUILDFR DEC TION - SPECIAL CIR RASC
a0 iv I hveby M.thin I sm excmp fmm th Ccto.us Lo.law fo,the
3 W H following mwa.(Section 70313,Humevs fm um,Code:Any city or country TEMP.Ir1ETFR OR ST.
E=5og which myuires a Pemril In cmoo c,alum,I ve,dmwlish,m rtpem any mmctme
p]mm in iseuma,a]w o,uirm the awlic tfv such peemiUu lle.ei stalGllml POW DEVICES
K m cp that he ie li¢mcal pwwmt to tba pate" of tM1e Conrmnols Licxnse V
ai PZ 9(cummcmingwiNSmtiw7000)of vioam3of0e Busies Pmt Coh) SWIM Rf, IC VALUATION
W'4_'rn o-Net he is cxcmp 0mafrom mdt b.i,fim Oeallegalexemplum Anyviol of ^ �u
F-ZQ S 7031.5bywryapp0ratt .permilwbjemsthe.pphcmtto.civil of -SWLTCHFS EXTORES p ,(J
out.,than five hon4cd ($500).
❑ I,vawrorof NcPm y,mmYmWloYenwith wn EW RFSIDFNTLLL CIR _SQ.FT.
gm utieireolccmo STORIES PE CONSTRUCTION
y _ Dill aodrtwmk,mdlM1e mre t.nmin Licdamoffered fo-uk( .) s
eM Rafessiom C ConOclm'a Liame law doe.rola b wnm of
pmpenywhomil impmvm0enao.wtdwhodamauchwark ' ghhi OCC GR RES.UNITS
awn employees, vided that wch impmvemenn.coat imerNW.off fm.sel H,
however,de brd 'ngwimp,vcmcnl iawldwithinmrye.rofcom ,Rco .
builder will luv 0e burdco n(pmving thtll he did rwM ddldo-lm o apt
❑ I,mownm the pmpcny.maxclmlvcly con mg wi li d to Qom' LUMBING PERMIT FEE I' DZONE APN
memml 0e qoA (Sm.70,14,Bust sM No :) Ka
I:ccma,Lms m plyloutownnofpropenywho improv and 1 PERMITSUANCE
whocom.forwch Jecu whh.co-thammfc)hc umtmOecm .clola AL -DRAINA VENT (FA)
Ilcwc Taw. FEE SUMMARY
❑ 1 mt exemp under S B C for this BA FLOW PROTECT.DEVICE DO D
SANITARY YN
Owner Dale RECEIPT'N
WOR" IC r SATIONDECLARATION D INS-FLOOR.ROOF.ARFA,CONI. SCHOOLTAX Y N
❑ IM1crcby off mttMtlM1eveace Emtc ofcmrnl to slf-imwe,o-.cmtifipte of �. RECfi1P1'N
RFS-PFR TRAP
Warkm'Ctmlpmutianlmunrceo-• cniOW copy Jertaf(Sm.3500,1ab CJwhieh PARK FFT Y N
cv,.all employce'f under this p.mil GAS-TA.SYS ESA-I INC.4 OUTLETS RECEIPT'#
Pu11cy# BUILDING DIVISION FEES
CO1nP^^y GAS-EA.SYSTEM-0VER 4(G) MANCHECK FEE
❑ CmtlRed mpyu Meby fmniahW.
❑ GmtiBM mpyu Bled wiN the city i.pecua Ivialm. GR ASFIINDUSIRL WASH?INTERCEPTOR GRADING FEE
CERTIPICATEOF EXFMPIIONIRO WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURAN
(Ili..caim rcd out be mmplmed ift�permit u fo-ae aallmOsm) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
ala.)
1 anJythm in Ne perfornuro<of the work far which Nis permiti.iawed,l.h.11 WATER HEATER W/VENT/BLECfR
no, mpby any pa a to my menror w.w baa n subject to do Workai PAID
z Cmmpcn tionlaweof C°lifmom Date WATER SYSTEM/TREATING
ApphD.e Reaip#
O O NoNCL TO APftJCANT:if,.flv meting this Ca laeof Eompdm.yco buaa NEW RESIDENTIAL PL IB. SQ.Pf. TOTAL:
F-' bccane whject m tM1e Wmkefe CanMswim pmv,,f the lAbor Code,you mwt
forthwith comply with such oavisiew or this penmt 001 he deemed rev4a& BUILDING FEE �.
y Q
CONSTRUCTION LENDING AGENCY SEISMICFTE
7-. Ihemaby affmm BntWme1'.comwcliot ludiug egtmry for 0eperfomtmaca f
U O the work for which thus Pmmb,i.inucd(Sec.JW],Ci ,C.) L / ELECTRIC FEE
Ismkr's N. PLUMBING FEE
U"
U 1.eNcr'a Add.. QTY. MEC14ANICALPUMU FEE �
U T crnify Int I love rt.d thi..ppfalion and awe Nn the ebrva infammim is Mf:ClIANICAL FEE
1" W .1.l.gree.comply wiN all city mdeamryardldroe.utd w¢laws rtlmingm PERMIT ISSUANCE,
F" huildiog.ons uon,mdhamby euNorirc rtpxotauvmof this cirymmtm upon rte CONSTRUCTION TAX
U Z .bovemrnhmN pmpny fm im,cuor,pmpoo-s. ALTER OR ADD TO WEN.
(We)ago,to uve,indenmify aW keep bm les Ie City of Cupcnma age ma
li.biliU ,j gmmu,avu.Mc.pcfumwhich meyuwy way.ccmeegdnu said Gry AIR IUNOLING UNR(TO 10,000 CFM)
i coo a oft line of this permit.
_ q / AIR HANDLING UNIT(OVER 10.000 CFAH
Signatu of ApplicantR'ontracax Dm, ` FXHAUSTIIOOD(w/DUCT)
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101,000 BTU) Dme Raelpt0
W' the epplicml or fuwrt Wlldfrlg o-cvpml mate ahuWe heau,iouarwaid IIEAIING UNIT(GVFJt I(q,000 BTU)
sed hY de Cupmoo Municipal CMe,Chaptt 9.12,utd the I health.fat Safely
Code,Section 25532(e)? VENTILATION FAN(SINGLE RFSID)
CIYm ❑No
Will Oeapplvantmfutmebuilding«apmt use,uip motdavicmwhihamat BOILER-COMP(31 IP OR I IJEO0 BTU) ISSjjANCE DATE
�M1a/NIgL1 Lir cvntamiwnu m delved by Ne B.Y Arta Au Quality Mmugmrcnl D
A'1
BOILER.COW(OVER 100,000 BTU) p ,
IBxuin? e
11 y ❑No NEWRESIDENT'IALMECH. SQ.ET. �£Q
I have mut Buhvmcksus mslem.la rtgahmomn t Chnper 6.95 of the 11�1I
California H[allh&Safely Code,Seaton.25#5,25533 mL 25534. 1 u tan i Bw
If the building dom nm cvnmtdy have a o, mt,that it is my msToosibi]ity to notify the (r
ocapw of the rtyubencnts which man be mel prior to usuarue of.Cenificete of Ur�h,
Oc<upm<y.
Gunner a autM1arD d°gent Ihm TOTAL: ISSUED BY:
Pmpe
10300 Torre Avenue
nt Cupertino, CA 95014
0 Building Division
(408)777-3228
(408)777-3333 (tax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--I have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--I have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are:
(this scclion need not be complded if the permil is for$100.00 or less)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I M11 forthwith comply with those
provisions. Date Z - -i- q S Applicant.
by Section 3700 of the Labor Code for the perfo an of the work for which this permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
Primed on Ren-rbx1I tm,e,