27906APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING--IIOLLCrRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PRo(:-MEDHANICAL
BUILDING PHO,INC'1'IDNMTIF'ICA'1'1f1N
FICA
PRRMrr NO.
27906 7 9 O C
G v
BUILDING ADDRESS:
SANITARY NO.
A1P'f.IGTI0N SUBMITTAL DATE
6leS UNIT# LOT#
tX
_ `CONTROL# J
OWNERS A E: PHONE:
' �/ / .2..
CONTRACTOR'S NAME: -
��qq 7 /006 WXg.IC NO: Q
ii'ri H£9Y/ODCZ /nv a. S £c Q L S
NIC
❑
,
ARCHITECT/ENGINEER: LIC NO:
ADDRESS: ti 12 q oft✓ „ n`p
5411' D S E'. G. ex` "711.
CONTACT: PHONE:
T' 1 n ^^ r/I O n n1 p / �s
lJ K. , 1. /-� /C< -7;7 0— U 7 �V
QTY. ELIiCPRIC PERMIT WEE
BUILDING PERMIT INFO
Bl. PLUMB CII
PERMIT ISSUANCE'
LICENSED CONTRAerproa DECLARATION
Chapter 9(n, (commencing with
licensed and
Ihereby afhmuhatl 3 of um
Section Professions
etf Division J of Ne Rmineas and Rofesaions Cade, and my license is in
pppLIANCGS- RISIDFNTIAL
- LOB D�c`
E/�■i�1K�aT_aF``eT '�/I/
PANELS '
e and
full fence and effect.
License Clusa Lic. # �? y par
UP TO 200 AMPS
Ilene — ECT S Dr�
' ARCHITECTS DCCLARAT'ION
I undcrsmnd my plans eM1sll be unit us puhllc records.
-
201 - I(MXI AMPS
OVER INX AMPS
$Q. Ff. FLUOR A rA
,
$/SQ. F4.
SIGNS ELECTRICAL.
Licensed Prufessinand
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that 1 am exempt form the Cmrrwuuri License Law for the
TEMP. METER OR POLE INST.
following reason. (Smion 7031.5. Business and Professions Cade: Any city or county
which reyuires a permit to common, cher, improve, demolish, or repair any structure
prim to its issuance, alsorequires the applicant for such permit to files signedsmtemem
POWER DEV[CES
that he is licensed pursuant to the provisions of the Cantrances License Law (Chapter
9(mmnmening with Section 7")of Division 3of the 9u1imessamd Profusion, Cade)
SWIMMING POOL ELECTRIC
VALUATION
or that he in exempt therefrom and the basis for alleged exemption. Any violatimi
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
OLD LEIS - SWITCHES - FIXTURES
r inure than five hundred dollars ($SIXB,
1:1I,asnwneral shepmpeny,nrmy nnployceswiWwegesnstheirsolecompcnmtion,
(- J[�'
NEW RESIDENTIALELECTR SQ. IT.
- STORIES
TYPE CONSTRUCI'Ilix
,ill do the so,k, andthe stmaturn is not imcnded oroffcied formac(Sec 7(v4, Business
and Proessions Cale: The Contractor's License Law does not apply to an owner of
progeny whobuiWxorimprovea thereon,nndwhwicessuchworkhimsslfnthroughhis
own employccs,pasvidear
l that such improvements e not intendedoroffcred for sale. IL
OCC GROUP
RES. NITS
however, the hawing.' improvementiasold withinone yearoferandermi,theowner-
builder will have the burden of proving that he did not build or improve for purpose of
�-
QTY. PLUMBING PERMIT FEE
sale.).
(3 Las r ropny, uesdusiv ennrsm
Cad:)
FLOODZONE
APN
construct the project (Se. Tk, Beninese ad Professions The Contmctor'e
Licme haw does not apply toanownemfpropenywuobuildamimprovw thereon,and
-
PERMIT ISSUANCE �
whoamwnsforsuchprojectswithacnmraGor(s) licensed pursuant to the Contractor's
Licrric Law.
ALTER - DRAIN&VL'NT - WATER EA
( 1
FEESUMMARY
❑ I um exempt under Sec. , B & PC for this reason
BACK MOW PROTECT. DEVICE.
ourimmirrmS
SANITARY Y N
RECEIPT#
_
Owner Date
DRAINS- FLOOR, ROOF,ARGA, GOND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX YN
;;-I hereby affirm that lhave eccnificem of conacmmaelf-insum, ore ccnificme of
Worken'Campensa,ion lnsumnce oroc<nif¢d copy lh:er1eof(S!ec.p3900,Lab Cc.)wrhi�ch
FlX'1'URPS PER TRAP i
RECEIPT#
PARK FEE Y N
cover.ull employee's under this permit. / 4./0 /U / — [ /
Policy # l
REC..IIvi
GAS- EA. SYSTEM.1 INCA OUTLETS
BUILDING DIVISION HIS
ComLL''any STG. TS FUys aO
ipc'nified copy is hereby famished.
GAS - EA. SYSTIN-OVER4(EA)
PLANCHECK FEE
GREASEpNDUSTRL WASTE INTERCEPTOR
GRADING FEE -
❑ Cenitied copy is riled with the city inspection division.
' CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE-,,s,„,�.. _. <ypp; rya,;
('I lik,cmma need not ba mmplend i true Finati6sfor nn0 hundred dollars($I(X))
GREASGIRAP;•,,; ,.
s�•".• •:..-
SOILS FEE -
SEWER -SANITARY- SI' ORM IiA'(2WF7:
ENERGY FEE
or leas) :• I.
-10A FA R NT/BLCCfR
L•�
W TERSY TING -
PAID
Dam
I certify that in the performan<e of the work ibr which this remail'�y Is I
not employ any person in any manner sat n, m become v;g' ,tl f or
Coommotionuassof Califnnem. Dane 5_ 111
Applicant -
NOI'ICH TO APPLICANT: IL after making this Cen[Bate of Ekempti ,y shdulA
become suhjectm the Workers Compensotion pmvisiom of the labor C ,you must
•"
E' IN RSI 1 MB. SQ. FT.
OT
fnnhwith comply with such provisions or permit shell be domed revoked.
i GATE,�
` t,I
BUILD[ 'E
SEISMI
CONSTRUCT ION LENDING AGENCY
that rthere is icacd,Stinn lending agency for OW'performance
❑m work for which this permit is issunl (Sec. 3097, Civ. CJ
I.kfor which
Leader's Name
� ...,..... �'s3''-^S• T
.a...s_,.��..
ELECTRIC FEE _�
Leader's Address
Q9'Y, MECHANICAL PERMIT F7113
PLUMBING I7LL
I certify that I have read this application and state ilia, the moose information is
I agree locomply with all city and cnuntyoMinmcesnndslntelawarelating to
PERMITISSUANCC
MECHANICAL FEEmeet.
buildingcouswction, and hereby amhariu mprocamtives ofthis city tocmmr upon the
shove -mentioned n for in, Gion
venae Y R puTosm.
ALTER OR ADD TO MECH. -
CONSTRUCTION'TAX
(We) agree nt save, indemnify and keep harmless rhe City of Cupertino against
dgmts. comm
linbilities,jurn adapenua which mey n , s
ay in mywccmeegainst said City
AIR HANDLING UNIT TO 10.000 CM)
in emseyuence of Ne granting of this panni,.
AIR HANDLING UNIT (OVER 10.000 CFM)
Signature of Applicant/Comrctor Dme
EXHAUST FOOD(W/DUCTT
PAID
HEATING UNIT(TO 100,000BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Recei
Will the the Cuantono tme MunicipalCode. Camsure o, handle haatilkh amateriA
us delisted by the Cupertino Municipal Cssle, Chapter 9.12, end the 1leshh and Safety
HEATING UNIT (OVER 1(10,0(10 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Cale, Section 25532(0)?
11 Yes 11 No
WilHhea licaut orfutumbuildin cecu ten use
pp g p
BOILER- COMPQIIPOR IW,” BTU)
ISSUANCE DATE
BOILER - COMP (OVER 100,000 BTU)
hazardous air comamimvtts as dehneJ by the Bay Area Air Quality Alanagement
Area Air Quality Management
Dislrin?
-
PAID
13 Y. ❑ No
e/�
NEW RESIDENTIAL. MECH. SQ. FT,
I have read the titanium, materials rcm
gnircents under Chapter 6.95 of the
OR 72
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
If Wa building does not currently lasso u tenant, that it is my responsibility to nosily the
a
'r
occupant of the ref'rements which must he met prior In issuance of a Cenilinnu of
Occupancy.
ISSUED BY:
Ownermuutho dagem 7 Dale
TOTAL:
OFFICE