27530 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY,OF CUPERTINOB ILDING�ELEUIIU AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27530
BUILDING,PROJECT IDENTIFICATION„
BUILDINGADDRESS: SANITARY NO. APPLICA'PON SUBMITTAL DATE.
Zfe_ (Ji(/ '( UNITRr LOTH ) ��1�
O S AMT:: J PHO E: z'!/_��CONTRACfOR"tiAME A�1 /� Q_/N'�./)�.�3+F70/ N/C CONTROI•.Jp
IRCHI :CT/ENGINEF.R: LIC NO: 4 ADDRESS �C/IZLP//-PS/C� /y/W- YJE` /5 ❑
CONTACT: PHONE ""r, ` '" * t ' - HDILDING PERMITINFOQTY, v; .,$BLEQTRIC PERMIT' '• FE
E ' LE F.QTPB..� pIONPERMITISSUANCE hl—(C`LICENSED CO ACTORSDECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIPTION
aZ m700F.fDI hereby Oap 3aftheam Homes,sed t lslons...Cc,lc..rommecense wish� 0 Scetion 7000)ol'Dlvislon3of the Business and Prnfesvionx Code.and my license is in ppNELS
fullfomeande[Ibm.LicenseClassLie.# UPT02MAMPS pale Corroder 201-Esta AMPS
'ZO,Z ARCHITECI"SDECLARATION OVER IOIIOAMPSLOOR AREA $/SQ.FT.
1 understand my plans shall hu used as public recnNs. _
F^ W SIGNS ELECTRICAL
Q
Licensed!Professional
DICm OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �.L.
Oy0 1 hereby affirm that I nm axe a Contractors License Law for the
W 3 W y following reason xamd 07031, oand ofdssions Cade:Any city or county TEMP.METER OR POLE INST.
E"�mJ wimmitauiresne.als lob theaMlicaimpro ,Itperdidnmah er repair anysWment
{Wi+� prior to saissuana,ala quires throvisi ns fthe hpdrnilto file a Luddri Law( hapset POWER DEVICES
Thal he Is It rsuant to the provisions of the ..actors License lanes(Chapter
9(eomm ncingwith Sedion 7000)of Divislon3o[th Business end ProfessionaCode) SWIMMING POOL ELECTRIC VALUATION
� G othat hdsexempt therefrom and hard drafo theaby aIle edexemant to Anyviolationof ���`��
[F Y Sermamt.LShyany dooddnntfora permit subjects OF applicant loacivil Penalty of OUTLETS-SWITCf{g$.pIXTI1RE$
not more th Bvehmtdmd dollen($500). NEW RESIDENTIAL ELECTR FT.
S .
❑ Lasow eroflheprnpeny,ormyemployeeswith wag saslheirsolecompensation, Q STORIES TYPECONSTRUCTION
a willdothewo mothesrmetumis timeadedoroffered rsale(See.7044,Businessrizz 5"0X;2_
and Profession. Carlo:The C frac t " Law does of apply to an owner of L O
propertywhobu tho) r ve Ir dwhodoessuclaw rklumsel(orthmughhis OCCGROUP RES.UNITS
.employees, her IF is randisa n lane. dorefferedforsale.lf,
h vevegthebuil 'n vearmissoldwi n arof ompletion,Ihecwner-
bidderwill have,eb ofprovingthuh didno but ori proveforpurpnseof
sal:.) x a
❑ I asowncrof ¢pro y,nm exei v ung wl hcomadcontmb 1 QT¥Y,ft,' a,"pLUMDING PERMIT. v x y y 1 PEE FLOODZONE APN
11
omerudl the p my (Seo.7044,Du cprofessional C c)The Contractor's v
License Lammers m applytoano o.'amwlmbuildsen pmvesthemormand PERMITISSUANCE
whecseLaw, ors Proleds commcmgs)LcenaW pursue to the Convecmle ALTER-DRAIN&VENT-WATM- EA ;;FEE`SUMMARY I
License Law, ( )
❑ I am exempt un c. B&P formula reason BACK FLOW PROTECT.DEVICE, z OUTSIDE PEES
SANITARY, Y N
OwnertC
Da[ RECEIPT#
DRAINS-f100R,ROOF,AREA,COND.
i❑ Iwreb f
WORKMAN
base.a it Fr of m^aD it LAR�nsureyyacertifiwte of SCHOOL TAX RECEIPT# N
IWorkera'Cem fa. a� nifiedeFy I (Sec.360,Luh C.)which FIXTURES PER TRAP PARK FEE - Y N
ra sllempind —it, o ` GAS INC.40UTLETS RECEIPT If
Policy N \ BUILDING DIVISION FEES
Company GAS-EA SYSTEM-OVER 4(EA) PL.ANCHECK FEE.
�❑ Ce ifled cnd, tmished
ified ced with the city inspection div' on. GREASEANDUSTRL WASTE INTERCEPTOR GRADING PEE
CCATE OPEXEMPTI_ON`/ OMWORKERS' GREASETRAP SOILS FEE
COMPLNSATION INSURANCEa,lue"eeliIbeeompleledi Kepernilisforenehundmddollare($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEB IL LBOodeasdI certify thpert. a of the work for which this permit is issued,l shall WATER HEATER W/VENDEIJECTR
not employ any person in any m as Io become aubjed to the Workers' PAID
O z CAPpmpeennruaim- .awsof California, aDate so WATER SYSTEM/IRBATING Dale eceipl#
zz�-I NOTICE.TO APPLICANT:If,after making the.Cerrificaleof Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
H fA hecomd sub car or the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDIN
2 (5 CONSTRUCTION LENDING AGENCY 5815
I hereby affirm that hem is a construction lending agency for the performance of T EE
U O the work far which this permit is issued(Sec.3097,Civ.C.) 2
FLenders Name
Lenders Address QTY s*x r •MECAAMCAL PARMITr "F8H 7 eL B a PEE
GUkI 1 certify that 1 have re4d this application and slate that the above information is MF.CIIANICAL F,F.
correct. l agree to comply with all city and county ordinances and date laws retain PERMIT ISSUANCE
tibuildin,,orwodion,and hereby sorhorize represenmtivesor Nis city to emerupon the CONSTRUCT' TAX
U z above-mentioned ve- entioned openy for inspection purposes. ALTER OR ADD TO MECH.
C (We)a o save,indemnify and ked armless the City of Cupertino against
liabilities,' menu,cost expense ch any way accrue age in l said City AIRHANDLINGUNIT(TO10,000CFM)
ru of the gruel o permit. 5/ AIR HANDLING UNIT(OVER 10,000 CPM)
Ignawre of Applies/% emeacmr pate EXHAUST HOOD(W/DUCT) PAID
Y AZARDWS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) DaReceipt#
Will the applicant or future building occupanlatme or handle hazardous material HEATING UNIT(OVER IOgfNq BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda Smtl Yes C3 No
x)7
El VENTILATION FAN(SINGLE REMO)
El Yes
Will
BOILER-COME UHIP OR 100,000 BTU) ISSUANCE DATE
hazanlous air comeminanu as defined by the Bay Amu Air Quality Management BOILER-COMP(OVER Iol B'IT) JUN 2 1995
istricl
El Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the Interactions materials requirements under Chapter 6.95 of the CI I Y Ur UUrEH I INO
Califomia l lealth&Safety Code,Sections 255D5,25533 and 25534.l understand Nat "-'
if the building does not currently have tenant,that itis my responsibility to notify the
occupant of the requiremmnts which must be mer prior m Issuance of a Certificate of
Occupancy.
n
Owner ormlhnrirzd.gem Data ISSUED DY:
OFFICE
r