27071 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO UH'bnr'-�'F�R �RNO.
APPLICATION/PERMIT PING PROD CT IDENNIGL 27071
BUILDING UI VLSION BUILDING PROJECT IDEYTIfICAI'IUN
BUILDING ADDRESS: /�/ I ' SANITARY NO, APRT TIONSUBM ALDAIE
20 gQ /�9aEY 6�LCy WIT#' LOTN �3 4
OWNERS AMB: C I - PHONE CONTRACi��NO�t� � 1•CNO NfC N7ROL
RCHTIECI'/FNGINEER:/UL/vl WCNO: ADDRESS: ❑
'ONTACf: ONE BUILDING PERMIT INFO
�� QTY. ELECTRIC PERMIT FEE
C4 V �J Iw� PERMIT ISSUANCE BLDG ELECT PLUMB MI;CH
` e
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Mintz Ihereby off.tluI.m licensed ludepmv'uiaa Mtbptc 9(mnumr'utgwith
� LOB DESCRIPTION
f\
00 Section7")of Division 3 ofthe Busitbs aha Pfokm uioCoda.and my lkeme is In PANELS y�-, 1 I `^'PTION
full face end eRat.
6 LicenseClas Lic.M IIP T02W AF1P5
N a d Detc Cmtroctac 201-1000 AMPS
FyF" ARCHITECTS DECLARATION OVER IOOOAMPS SQ.17.MOOR AREA S/SQ.FT.
0 Z,'_p I umrdrnwd mY pWa shell be used u ptNk meads.
W SIGNS ELECTRICAL
<'2' Lianscd Pmfmiavd
W,=< OWNER-BUILDER DECLARATION SPECLkLCEtCUIT/MISC
seax OatVF. 1 bcneby Tum thu 1 em exemp from Jr Convrrmis Idcvase Law for his,
W3p-N¢ follmvingte..+an.(Stttim 70313,Busines.rd Dofcaims Code:Any my or county TEMP.METER OR POLE INST.
�.] which te9uites a Permit m emsmnm,alter,improve,demolish,or M'm sny wueture
Prig to its isnuance,u1su tryouts the applicant for much pemut to Nle usirW swrnRnt POWER DEVICES
T <0 Ihet he is li,oscA pursuant to the pmvieioa of the Contractors License Isco(Ch Iter
9(canmencing with SeNm 7").f DoEm.3 M the Busrc and Pmfasiory Code) SWIMMING POOL ELECTRIC VALUATION
y athu he is exempt dtemhom and the besis for Ilse.Ikged exemption.Any violation of
> Section 70315b I tfor. t b Else hand to.civil Penalty of OUTLETS-SWITCHES-FLXTURES
CZQ Y•^YdrP Min PnI. •u Jcm •ppl
f�px
not m1. to five hundred y,mm1300). NEW RESIDPNTIN.FlEC1R SQ.FT. ORBS TYPECONSfRUCHON
ClI,nowmvofmc
y3�KK pnpemy,eisnot mymwith wegcauthcirsok 044'Buetim,
will dothcwurt,adlhc swmmmcuor'n Linc Lawdoe notapSce7 . woelw
and ermrdsimt.Ctdc:The Contractor's License law docs not.Poly In an owmla of
pmlcny whobuihlsaintpnves 0laeun,and who iLrn each wont hlmselforJwughhi. G R P RLS.UNITS
foovuwoemployeutichn, dt,,rose atsomenuum mtinteddmoffvd muwoer,
Witer,wthebuildingordert oproem usoldwIWnot year or mmmocfor sm,oeea TOTAL:
builder wJ1 love the bunko of pmviM dw he did not build m itmrmve for pnpne M ClIkY
uk.).
❑ I.0 oxw of the propenY•amexclusivcly ronlrrring with liansd cmimnmlo QTY' PLUMBI ERMIT FEE FLOOD ZONE APN
constnrct the projcn(Sec.7614.Businne ad Ptofcuioro Code)The Cmu. m's .a..
Ureo.tawdms^ulspplyt...wnnof popmy wlobuildsoimpmvn rhes on,end PERMIT ISSUANCIi
who conlmcis forsuch Ptuj"with a conhactuq()licenred plu..11.the Cantnecon's AL'IFJt-DRAW&VENT-WATER FA
Lt.taw ( ) FEE SUMMARY
❑ I.m exemp alder Sec. .B&P C fm thu mosso BACK FLOW PROTECT.DEVICE E FEES
SANITARY Y N
O� Late-WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,COND. SCHOOLTAX YECEIPf1 N
❑ IlseehyaRrm that)have. or
fied[t^rvn tomf(- un,ar eati.)whiff FlX'DIR -PFR TRAP RECEIPTa
mhcns'Cmmfcnwim laurvuamacatifedupy llrmnf(Ss.38W,lab CJwhich PARK FEB YN
cuvm
all employee's undo this permit. TAS- RECEIPT'M
Policy 0 BUILDING DIVISION FEG4
CnmP^ny GAS- ECK FEE
❑ Cemtif i ropy la M1emby funtishcd
❑ CrniEd copy u fled with Ne clry lnspeaim division. GREA
CERTIFICATE OF EXEMPTION FROM WORKERS GREA I
COMPENSATION INSURANCE
(This sectim need not be completed ifthe pemtit is for one hundred doll.n(SIW) SEW' - T I' '. FEF.
or Ica.)
I antfythat in the penman'the wort but which this pump is issued.T most 11 WA F
not employ any Pero^ many mummer so n to bccmte subj>-t to the WootenPAID
Compeu.tionuwsmf C.IJa•;t Due WA Date Rettig♦
O z Appwau Ism
z 2 NOTICE TO APPLIGNT:If.after making Ibis Certificate of Exanptlon,you should NEW TOTAL,
V] Imecvra subject m Else Watch Canpcwuol prmri.iam of IN,,Labor Code,you own
fonhwilh canply with sock rovisums olhis pemmit shall be clamed revoked. amu .ate BUILDING IEE
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
I heeby dEmn that thee is a cauuvetion ladingµant,for Ilse peAanrtmrre of
TIAL FlEC1R1C FEE
U O
the coat for which this pammt is iuvetl(Sec.3097,Civ.C)
Isnder's Name
OF Lerch''Addma QTY. MECHANICALP PLUMBING FEE
U I certify dru 1 have mean this appliotim nal mum that Else,abuse information is MECHANICAL FFJ:
caa
nt.l.gme to comply with alWam
l city cty mdinumateb
ras.d re laws relating p A
F" 44
huilding mnswctito hcmby 0wri mcpnenldivn of Nis city tornta upon the
V about-mrnliond pct ny'aims �t Purpovm. ALIERORADDTOMI?CH. CONSTRUCTION TAX
(we>.gme m rr tem IwMeu the city orcmpeminm agent
lisbilitie,jd .sats and which may in.ny wont rlc eg.iat 'd City AIR HANDLING UNIT 0010.000 CFM)
uconuyuena gtmuin pumit.
AIR HANDLING UNIT(OVER 10,000 CEM)
ignnt of ice^ u.c., EXHAUST HOOD(W/DUCf)
PAID
I YAI LOU'S MA'11iRIA S DISCLOSURE HEATING UNIT(TO 100.00 BTU) - Doc Rmci"#
Will the eppli t afuu.building«cu'm vee m lwdlc Icor".Jou.numeric
defined by the Cupertino Municipal Calc,Chapter 9.13,end de Hedth and Safety IIFATTNG UNIT(OVER 1 W,000 BTU) TOTAL
u d
Code.Salim 23532(a)7
ll Ya ❑No VENTILATION FAN(SINGLE RFSID)
ISSUANCE DATE
Willthe.iglicenl orfutum buildimgmcvpvnu.Nuipme^tadevitts whiehmrit BOILER-COMP(31TP OR IW,000 BTU) P1t n P�yt
�heeudou.air cunlomirunis as,defi^d by Ilse Bey Amen Air Quality Management HOILER-COMP(OVFR I00.000 BTU) Y,
anon.'
{ ❑Yo 11 No NEW RESIDENTIAL MECII. SQ.FT. SEP g3 1994
♦ 1 have trod the haoa.dous mauer ad,rryuimmcnn uda Clupler 6.95 of the
Califmaia Hedds&Safety Code.Satimm 255113,25333.M 25534. 1 uMenud that CITY �r UUrrnIHSU
if the building dines mu
ot Burne dy have.tmsm.lh.t it is my nespmaiMlity to notify the
meev,sum M the mquimmenu which mum k mel Prior to inumra of.Cenificue of
a�,paay. 1vV`
Own,m euthmimJ ugcnt Dote TOTAL: ISSUED BY:
OFFICE
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