27332 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING- 's.b. TR AI. PERMI'rNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27332���Q
BUILDING PROJECTIDEN1'IFICATION L G
BUILD A 1a SANITARY NO. APPLICNI ON SUBMIT-PAL DATE
BNIT# LOTH 1\Z
N NAME /` )k1 ryL CO AC9' %NA / Upgo
N/C CONTROL p
�ARCHITE /ENGINEER: LIC NO: A E
,Kr �A'irL a.�-rGJ ❑
CONTACT: PHONE: QTY. LECTRIC PERMIT FEE Ev v BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
PERMIT ISSUANCE T4
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDFMIAL y
I hereby affirm l um licensed under fCha ter9 c mmencing with JOB DESCRIPTION
GCZ Y Pm Professions
p (n
p10ti�0❑ fall macrtiand of Division]ofthe Busineas and Rakaions Cale.and myliuveisin PANELS
F�Uu full..class ea.
I¢„Z faU Liunu Class Lic.p UP I'02W AMPS t1'/eV1ag/yw_ff^]k`IL-J4/i,—
m?y Dae Contracmr 201-101111 AMPS
ZOY'it� ARCIIITEC`PSDECIARATION OVER Ig10 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
OZ_❑ Iuadenwndmy plans shut]be,used a pahliemewda.
F y W SIGNS ELECTRICAL
Licensed Prolesdmisl
�yuaJu OWNER-exempt to.on,
SPF:CIAI,CIRCUII'/MISC.
P+20aF- I hereby affirm them I am exempt from Ne Cosigns Co License Law for the
m3tr,rn whlowiequireoa Permit
tn]O3L5.Buslnessand improve.demolish,
Code:Any airy or county TEMP.METES OR POLE MST.
whichitsissaapermit re wnswn,aegimprove,demolish,firepairnaystructure POWER DEVICES
primtoslicensed .also Cammrramtth the visiosocant for the Co merit.LienseLadatemment
WK OC
Ran heisncingwpursuanttothe)ofD provisions of the Ce Bimini
rs Licmulaw(Chapter
daX 2LL 9t hat heisexemithSemian00(1dthe Division Sof theBusiness and .Any violation of
SWIMMING POOL ELECTRIC VALUATION
IyZN or Section 703
1.5 by aheafmmnt f the basis fonhealleged eacmpti to Anyyviorialty of OUTLET'S-SWITCHES-FIXTURES
f.Z< Section]Chu iv uundredidomrs($50mtit subjects the applicant to acivil penalty of
pnot more than five hundred dollen(f5IX1). NEW RESIDENTIAL ELECfR —SQ,
❑ I,asnwneroUhepropmy.ormyemployecswitb wages as theirsolecompensaion, STORIES TYPF:CONSIRUCI'ION
a3— will do the w,vk,wid the amenore isnot immndedoro(fated for sale(Sce.7W.Business
and Professions Cale:The Contractor's Liana Law does not apply to an owner of
property whobuildsar improves hemon,and whodoesauchworkhimselfordoughhis OCC,GROUP RES.UNITS
emp]oyees.prm idedNet suchimprnvemtrnine
cntscot ndedorofrered(orale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of parsing that he did not build or improve for purpose of TOTAL:
sole.).
❑ Lmownvafthc Property,amexclusivelycantnctingwiNlicensed...Nona.to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.IN14,Business and Professions Code:)no Contractor's PERMIT'ISSUANCE
License Lew does nm apply to an owner of property w ho bu i]ds cr improves Hro
ern,and
whoconeacis for such projects with ucomseloch)licensed pursuant to the Commetoes PETER-DRAIN&VENT-WA'1'fili LPA)
License law. FEE SUMMARY
ElI an exempt under Sec. ,II&P C for this reason BACK FLOW PRO'T'ECT.DEVICE qE :ES
SANITARY YN
Owner Dale RECEIPT#
DRAINS-FLOOR.ROOF,AREA,COND.WORKMAN COMPENSATION DECLARATION SCHOOLTAX V N
❑ em'Co afRrmthat lhave aeor a cemcuTcnnsemtowf(iee.380,LabCficaech RF.CF.IPI'#
Wnrkm'Compenation Insurance nracenifiedcopy Nertnf(SecJSIXl,Inb CJ which FIXTURES-PER TRAP PARK FEE V N
covers all employee's under this pemdt. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT N
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
❑ Cenified copy is hereby famished.
❑ CeniGeJ copy is Bled with the city inspection division. GRWP/1NDUSTRL WASTE INTERCEPTOR GRADING FILE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section needrim be completed ifthe permit is fsrone hundred dollen(5100) SEWER-SANITARY-STORM PA.20[IFT. ENERGY TEL
a IessJ
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER WNENT/ELECfR
.at employ any person in any manner so m to become subject m the Wmkeri PAID
Compensation Laws ofCalifornia. Date WATER SYSTEM/TREATING Date Receipt Is
O z Applicant
0 TO APPLICANT:If,after E. makin this Comficme of Exemptionn TOTAL:
g p'n ,you should NEW RESIDIiM'IAL PIMB. SQ.PI'.
IzNOTICE
+ VJ become subject to the Workefa Compensation pmvisioro of the Lebow Code,you must
5 forthwith comply with such PmviOnro or this permit shall be deemed revoked. BUILDING FEE
PW. ca CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 hereby not that hem is a construction lending agency for the performance of
Vthe work for which er
this pmit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
IT, P PLender's Name
Lerdcr'a Address QTY. MSCI IANICAL PERMIT FEE PLUMBING FEE
U 1 certify that I have read this application and Cone that the above information is _7
0. correct,l agree to comply with all city and county ordinances 4nda4ae laws reason,m Pf"- ITISSUANCE MECHANICAL FEE
building comtructioa anJ hereby authorizertPreaenmoivea of thiscity touter upon the CONSTRUCTION TAX
U z above-mentioned propeny for inspection purposes. ALTER OR ADD TO MECH.
r.
(We). e to save,indemnify and keep harmless the City of CuNtaino agaimo
it a. gnerds,costa swinch pro,man,way reemeagatnst aid City AIR HANDLING UNIT(TO Io,000CFM)
in c ncco caran ago, pctant.
2L_ Dae FM
AIR HANDLING UNIT(OVER to,"C )
Si art of pplican on or EXHAUST HOOD PAID
HAZARDOUS MATERIALS pISCLOSURF.
BEATING UNIT(TO IWfXN BTU) Date Receipt#
Will the applicant or future building occupant store or handle broadens material
as defined by the Cupertino Municipal Code,Chapter 9.12,andthe Health and Safety HEATING UNIT(OVER 100,(100 BTU) TOTAL:
Cade,Section 1125532( '!Yes ❑No e)
❑ VENTILATION FAN(SINGLE RFSID)
ceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
W ill theupplicam or finurehuilding�xcuPant useeyoipmemor Jevi
•haradoua air cornaminants as defined by the Bay Area Air Qualify ManagelnefB BOILER-COMP(OVER 100,OB)BTU) P' A f p
District'! q
p�
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. Nov
I have read the hazardous materials mquiremro #NYIcs under Chapter 6.95 of the 23 1O
California I Icahn&Safety Code,Sections 25505,25533 and 25534. I understand that /a7
if the building does not currently have a enant,that it is my responsibility to notify the c
occupant of the rcquiremema which must be met prior m issuance of a Certificate of C/'y ut. L
S WOU
Occupancy. II
Owner or authorised.gem Date ISSUED BY:
OFFICE