27856 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27856
LDING ADDRESS
�y�G SANITARY NO. APPLICATIONSUBMITTALDATE
VV2- /✓' L UNIT# LOT#
1011EHERS NA f PIO E: w CfOR'SN M LIC NO N/C CONTROLN
Allu 6•t Z
ARCUITECTF GINEF. : LIC NO: A D ESS.
� r-� sai
CONTACT:MI
PHONE: 9.a-'Jd_-I BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
LT P M M' I
PERMIT ISSUANCE
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RESIDENTIAL IOBDESC IPTION
p y�Z I hereby ofGnn Nat l am licensed uneerprovisionsofarp¢r9(commencing with
uFi 00E Section 7")of Division]of Ne Businesxnd Prommions Curie,and licenxisin PANELS
aUU full force and effect. �/�Q-� '
m,,Z¢e Littnx Clercs I.ic.p :r UPTO2W AMPS
m<<Oy Duln Cumra<mr L.✓J/ 201-1000 AMPS
F-D ARCHITECTS DF I.ARATIGN Vase- SQ.PT.FLOOR AREA $/SQ.IT.
ZOy-- /
0 z !) I derstend my plans shall he used n public ta-Ns. OVER IOW AMPS
�
F SIGNS ELECTRICAL
Licensed Profevaional
OWNER-BUILDER tau n fromiDECLARATION SPECIAL CIRCUIT/MISC.
�ngS,On.0 1 hereby affirm that 1 am exempt from the C mations ro License Low for Ne
fallowin+34y whichngrenon.(Sati-n?Wl3,Husmess unions,
Profession Co de:Any city someone
TEMP.METER OR POLE MST.
which require n perminn i:mrthe ahcq improv -lith,file
repair say ewnure
i-�
priorto its issuance, rey resifie up li such pe it to ase Law(Chapt r POWER DEVICES
'0 that he is licensed pursue rsimu of the Come mr'e License Lew(Chapter
9(connomman action]WO)of Divisier3ofthe Bu assaM Pr-Teutons Codc) SWIMMING POOL ELECTRIC VALUATION
,Moo mthmimme mit theufromand the basis for the alleged xaninum.Anyvioli ionof
LyQSection 703 5 by any applicant for a permit subjects the UTLEfS-SWITCHES-FI%TURES
Fp J pliant to a civ penalty of
❑ t more th a five hundred dollars($500).
/ $
Kpr-pcny,ormyemployaswithwa Motheirsolecompetssalion, W
NERESIDENBALELECIR .ET.
Wim ❑ Lasa k,. e STORMS TYP.CONSTRUCTION
a3_, willdo the o,t,andihe structure is notimendedoroffere formle(Sec.]1144,Businas
tied Profes inns Code:BIm Convsm /s License Law d snot apply m un owner of
properryw buildsor'mprom there n, advaZess h work hiruelfor through his
ownemplo s,provi Mn h' ntsuen mm�dedoroffered forsale.If. OCC.GROUP RES.UNITS
however,th buildi none ear-(completion,the owner- T L:
huilder will ewer gthnhe Jidnot ildorimproveforpuryoxof
rale.).
❑ Lazo nerofth pro ny,smexclniverycon gwith licenxd conrrsetorsto QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct t e project Se 70l Bus umodai,Code)The Comracmr's
Licemal. downer yman- nrifu an sty who builds or improves thereon,and PERMIT ISSUANCE
VF—
License
cis forsuch pmjeets with t trxmr(a)licened pursuanu-the Contrxnofs ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ Is exempt under S ,B&P C for this mason HACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Date DRAINS-IlOOR,ROOF,AREA,COND. R EIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TA N
Cl Us yn/Brrn that,have a ceniftcate ofcomen,to self-insum,-r a certificate of %TGREs PER TRAP i RECEIPT#
Worker%Compensation lnsumnee oraartifeJ copy there-f(Sec.38W,Lab CJwhich I 2=0PARKF V_N
- <oversallemployee'sun Ois� 0 O GAS-EA,SYSTEM-I INC.4OUTLETS i RECEIPT#
Pulicy# I� UILDW0 I NFEES
IrMs
pyis her
GAS-EA.SYSTEM-OVER4(EA) P i
Ceti and e yfumis cd. G.
Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADIN -E
CE LS FE
MWORKERS* GREASE TRAP SOILS
COMPENSATION INSURANCE.
(This train need not be completed permit is peris for one hundred dollars(1100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
Vacantly n in tha psa f..nine the work f which this permit i.' I Shan WATER HEATER W)VEJT/ELECfR
not employ sty parson in any man# s wme subjal kers' PAID
Compensmi L.awsof Cslifomin, Da WATER SYSTEMITREATJNG Dem Receipt#
ZZ Applicant
Q NOTICE APPLI NT t 'ng/Ti c f emits you should NEW RESIDENTIAL PLMB. SQ.PI'. TOTAL:
t•+ f/1 becomes jcalm, r es -tepee M. t($ tjm r .'gens o t e La not.you most
G3: forthwit omplyw Provisions orh's itshallhed adrevoked. BUILDING FEE �-
z NSTRUCf1ON LENDING CY SEISMIC FEE h
I ereby affirm th Ithem is a construction le g agency for the perfarmence of ES.M ELECTRIC FEC �a
U Q�+ mi
thew kfarwhichthispertisissued(Sec. ,Civ.CJ
CI. F" Lend 's Ntune
Lend rs Address PERMITQTY. MECHANICAL PERMFEE
PLUMBING FEE
L) certify thm 1 have read city
and
and state that the shove information is
� sore to mwm I all alt MECHANICAL FET.
gra- p yandcpresomNinanceannd. 1lxweruporatIn PERMIT ISSUANCE
thin !-l a. onwctio herinspethmiu purposes.
iivesof this ciryio ter upon Ne CONSTRUCTION TAX
L) z abov Wen to Profanity for inspection keep co ALTER OR ADD TO MECH.
(We)ague nt save,indemnify tied keep harmless the City Cupertino against
liahilitiee,judgnmms,nuts and asperities which may in any way true ege' st said City AIR HANDLING UNIT(TO Io,OW CFM)
inconsequence- th I of thio
AIR HANDLING UNIT(OVER 10,000 CFM)
ignatureof Ap Want/ mactor [5.6, EXHAUST HOOD(W/DUCU
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO 100,000 BTU) Duro Raeipt#
Will the applicant orfumre building occupant store or handle haaardour material
sea defined by the Capetian Municipal Code,Chapter 9.12,and the Health and$.fay HEATING UNIT(OVER 100,010 BTU) T
Code.Section 25532(e)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID) rt aaw
ISSUPCE DATE
Will he applicant or futurebuildingacupuntusa equipmemordeviceswhich emit BOILER-COMP(3I3POR 100,000 BTU) //p����- /p ®
meardour air conamonsnts n defined by the Buy Area Air Quality Management BORER-COMP(OVER IW,000 BTU) (fry W
Disuia ❑
? .,/ I�a
Yes 0 N NEWRESIDFALMECH. SQ.FT. ` 021
1 have mad the haserdous materials rryuiramente under Chapter 6.95 of the (/h 99S
California Health&Safety Code,Sections 25505,M533 and 23534.I understand that
firm building k as not currently haves unapt,that it fairy,responsibility or notify the
occupant of the requirements which must be met prior to issuance of a Ceniftcate
Occupancy. all
Owncroranhorixdagent Dau TOT ISSUCD BY:
OFFICE