27112 I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C
CI'T'Y OF UPERTINO co,"'u�.'RC7V Ai. PERMH'NO.
BUILDING C DIVISION APPI.ICATION/PERMIT PLUMBING-MECHANICAL. 27112���Gn
BUILDING PROJECT IDENI'IFICA'ITON
OBLONG NG ADDRESS: SANITARY NO. APPLICATIONSUBMITTAL771
OWN II1�` r PHONE: OTAfjl'O�nAMO LICNO:
,.1 bvu& CC..����77 r L� N/C CONTROLp
RCIII'I'l C/11NGINEER: LIC NO: DRESS: -J ❑ all
CONTACT: .�{�ONE:
QTY. ELECTRIC PERMIT FEHULLOING I'EItMIT INFO
RC'6eRT I • ��W I ' 1 E:
BLDG ELEC' PLU MECH
(4o S' 425 — Ito l� PERMITISSUANCE
LICENSED CONTRACTOR'SDECLARATIONAPPLIANCES-RESIDENTIAL G� 10
OCZ IlmreM1y wffirm ma l unlicensed undcrprovisinnsnf Chupter9 Dommeocing with
Y100 Section 70001of Division 3 of the Business and Professiom Cude,wn ,license is in PANELS
F4V F fall force enJ cffcc6 6 1#1Y
R, Licrnse Clav Lic.x �/ UP T0211(IAMI'S C
rF<y D cjin Comre��r ii 201-IIM9 AMPS v
Eo,Z, ARCHITECTS DECLARATION - SQ.FT.Il,00R AREA 5/SQ.IT.
' z0o,— l understand my plus shall be,used as public records.
OVER I(IfI0AMP5
SIGNS ELECTRICAL
Ce
�� uu��2, Uram"I Professional
OWNER-BUILDERDECLARATIGN SPECIAL CIRCUITIMISC.
!'k OyU I hereby affirm that 1 am exempt from the Contractor's License Law for the
u131r-y following rcusoo.(Section]03LS,Business and pn sato tale:Any city or cnunry '1'13 MP.MIST ER OR POLE INST.
l�E1 which rcyldres a permit to contact,aliet,impru ,demolish, repidr any structure -
��yS In its issamca,clvoreuirealhea licantl' such ton1mr, asinedxutemom POWER DEVICES
prior 4 Pp p ug
0 that he is licensed pursuant to the Provisions o the Contrucrr's lice Law(ch.pten
�) SWIMMING POOL ELECTRIC
0.0.0 y(mmmencing with Section 70W)of Dlvisl 13 o[mo Ouxlnesa end fesslons Code) VALUATION
_,o, or that he is exempt herefrom and the best or the alleged exemption.A viola0onof
FZa Section 7071.5 by any applicant for nit subjects the applicant a as it penalty of O11TLEf5-SWITCHES-FIXTURES O
lin mmethanfivehundraddollars(E 1. NEW RI?SIDIINTIAL ELECTR _SQ.IT.
C m n❑ I,acowearofthepropcny,or employceswithwwgesmtheirsoleco motion. STORI S TYPE CONSTRUCT NI
y3— will do the work,and thes0uature notimendedornfface fureele(Sec7044, usiness
and Professions Cade:The C vactols Littnu Law d«s not apply co an net of
property who boildsorimpro stherton,and whod«aimch work himselforNm hhis OCC.GROUP RFS.UNITS
wnendr,aeapmvidW lmchimprovemenuarcnocimcndednroffertdfor e.lf,
however,the building or provement is sold within t a yea ofaxmpletio the or- TOTAL:
builder will have the b den ofmoving that he did no diderimpow ryos of
's1a')' QTY. PLUMBINGPERMIT' FEE FLOOD ZONE APN
❑ I,us nwncnd cpropety,amex<lusiv < ng with llcen tato
f mnsloal the P t Se 7044,Buxinsx a afe"mr,Cc The Co erac, x
K License Loodoust nlapply mtatowne hobo it r ,and PI!RMI9'ISSUANCE
whnconowl,fors chpo tswi roar( Ii cryShc um to lh ommctore ,
'License Low. ALTER-DRAIN&VENT-WAS'ER( FEE SUMMARY
j ❑ 1 um eaeept a der Se .B&P for this maxim BACK II.OW PRO'I ECT.DEVIC r ' 'LSII L '
SANI'T'ARY Y N
)"a, Dam RECEIPI'p
IlNA1N5-pLOOR,ROOP,A ND
WO KMAN MPF:NSA'fION D13CI:ARA ON % SCHOOLTAX YN
❑ Iheubyaffirm tihereucenifieweofconsemtoself' are,oracetificu of VENTURES-PER TRAM. A ,. PARK PEE YLCEIPI'N N
Workers Compensacio Imuran«oruttnifiW copy therm Sec.Jg00,WbCd which P�
coven ell nnplayce'r a hhis prnnit. /� GAS-IA.SYSTEM4 1 4 oLYFU f5 4 RECD, f p
Policy / �' BUILDING DI SIO wps
Cr^p^^Y - GAS-PA.SYSTEM-OVER 4(`)*s / t', PLANCHECK FEF. O
❑ Certified y a—.Iced. t
❑ Ca tied copy is filed ith the city inspect niivisim GRHASE/INDUST LWASTE INTP, F OR (GRADING WE
CERTIFICATE � E ION FROM RKERS' GREASII'1'RAP ( O S EC
COMPENS 'll SjSRANCIi / ' -
(Io"atlionneed heco e Jit pcmtitirl'orol undreddallwre(SIIX� SI? ['R-SANITARY- RM EA.20017. E p FF
or Ic xJ
Icerify atinth afthewakfor wM1wOlci.Permit is issued,l shall W RR H' W/VENT CTR /)
and employ Y f airy tanner so in Irkbecome subject to the Workers'
!9\}I �' A HRS TING
Co nsati nSlifomia. Date N s - >m R eip p
O z Applicant o
Z O NOTICEPPI. ANT:If.after making this Cerificam of Exemption.you should NE RP 1 IAL B S OTAL:
rn beet me subject to th Wo trees Compensation panes ons of the Labur Code,you must
afool with m 'ly such protiitionx or tats pemth hall be deemed revoked. Bu c EE I.
f.L1 t. / v" - SF.ISMI FF.H
nq' Of
CO en is ac ION LENDING AGENCY �
✓ 7. 1 henry affirm t u.it is a construction 7,Ci6.gene,for the Performance of
thew rk fur whit is permit is issued(Sec.7097.Civ.C.) . OTAL: EhF.Cfil F '
Londe Num
Lmderx nedrcxs QTY. MEC( CALP RMI PHE PLUM NO FEE
U I acuily that 1 have read mix application aml voice Orr toe have information is .�
"mewl. l once to comply with all cilyandeouncy nnl'o ncesundstut, awsrelutngm PIBMUI'ISSUANCE 4`u MEC(&6 '1311
�-' building crosiruclion,and hereby emhoriu represenunivw of this city to enter upon the
'U Z chow-mentioned pmpeny for inspection purposes. ALTER OR ADD TO MECH. CONS'fRUCI'ION TA%"
(We)ugme to save,indeenif and keep homeless the City of Cupertino against
liaties,' gments,cosls ande sea which may in any way accrue against said City AIR I IANDLING UNIT ITO 10,WO CFMI
e the granting it. �y AIR HANDLING UNIT(OVER IR0011CFM)
S--gi
.ignatum Applicwm/Camm r Date EXHAUST k10001W/DUCT)
PAI
HAZARD U MA9ERIAISDISCLOSURE HEATING UNIT(TO 100,000 BTUI Data «eiptq
Will the applicant or occur uilding occupant store or handle haeadous material
Chapter 9.12,and the Healthand Safety HEATING UNIT(OVER 100,000 BTU) \ TOTAL:
us Jcfnml by the Cupcninn MuniciPW Code,
CWe.Section 25531(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will the nPPlicum or future building omupnl usceyulpmenl nNevlces whlchmtim
BOILER-COMP(3HP OR 1010,000 BTU) ISSUANCE DAT
( ter—li us air conwminunts as deficitby Ice Buy Arca Air Quality Management BOILER.COMP(OVER 100,000 BTU)
Dlsoim'
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FP. P-A B D
I Larva¢ad the Incautious materials requirements under Chapter 6.95 of the
California llezoh&Safety Code,Smtions25505,25533 and 25534.lunderscardmat �IAY 995
if the building does not currently have a recent.lhat it is my responsibility to notify me
.up.,of the requirements which mast be,met prior ,,issuance of w Ceniecate of
Occupancy. I Ue6H)'INO
Owner nr nmhoriud"gem Data TOTAL: ISSUED BY:
OFFICE