27757 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOL PERMIT NO.
APPLICATION/PERMIT ...... RG n-,ECHANTCAL.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27757
HUII-DIBG ADDRESSCut & v���/ � �) SANIIARI'NO. Alq'LICATI(IN SUBMfI'I'ALIIATIi
- •-a UNITX 1,01'Y �1 ��1 i
OWNERS NNNAME' PH NE: CONBAj:LjA LIC NO: NIC C-7A,X
.2 6 �—
. UNI
AKCHTE /ENGINE : LIC NO: ADDRESS v
CONTACT: PHONE: >v' ape g4,A,�vr- ----:v. c r" i -s ".,,'I O Ng:BUILDING PERMIT INFO
.QS'rrABI:ECCRIr PERMIT..? ) 1 r 'FEE?,
ELECT PLUMB MECH
«` PERMITISSUANCE 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ES
na0 Ihereby affirm thatl3 of
sesimclrold Pmanaism,Conle,an ommenensecirt,with
—OO Section 7")of Division 3ol Nc Businns antl Professions Code,and my license is in PANELS
.,r, fullforceandeffect.
<ZLL1 License Cans Lic.M UP T021p AMPS
:n?y Date Contactor MI-I"AMPS
�NZ ARCHITECTS DECLARATION OVER IOIp AMPS SQ.FT.FLOOR AREA S/SQ.M.
Z—., I understand my plans shall be wood as public record..
-W SIGNSELECTRICAL
Yj Licensed Professional
sOWNER.BUILDER DECLARATION SPECLU.CIRCUIT/MISC.
5g V u I hereby offirm That 1 am exempt from the Contra hu',License law fa rhe
O rQen following won.(Section 7031.5.Business and Professions Code:Ary city clearstory TEh1P.METER OR POLE MST.
—y J which requires Permitter,a Permit w mmurts,alimprove,demolish,or rtW any stacmre
-!M psimm its lswaneaalw requwu Ne applicant far such pumiNo file a.ignd.uwrat POWER DEVICES
Y?p that he is IiansM punuwr to The provisions of The Contractors License law(Chapter
9(commencin wish 7000 f Division 3 of the Business and Profusions Code SWIMMING POOL ELECTRIC
.xo (commencing )o ) VALUATION
w aNat he is exempt therefrom rod Ne buisfm Ne alleged exemption.Myvinluinnof VDETSSW17'CHFSFU(TlIRES /a
_ZQ Section 7031.5 by any applicant for a permit subjects the applicant toacivil(cnalry of '
i=< not more than five hmrdrtd dollm(S5W).
_,e, ❑ I.uownmoftheproperryormYemployttswith waguuthe'vwlerompeuation. NEWRESIDFNTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
_3=o will dothe work.saddle swclumisnot inuendedoroffered Intrude(Sm.7040,Business
and Pmfeuions Code:The Contractors Liame law does rut apply to an owner of
Dwo pmperrywYcestpdsorimpmvuch roprove whodoenot
ouctende himselforthwugh Ms
employeu,providr i pr suchen iovememsue neyourndcdmafferedfor We.q OCC GROUP RES.UNITS
builuhowever,Ne Wilding or improvement off nrnr i.hath a did oneyovm completion.psa,mn of _
builds will have The burden of pmving then he did not build or improve for puryose of
ale.). r? *�.-n..,�na.-tee.• biz s.y jc 4_ ..r..��.r..«.
❑ I,uownerof drc n /^4 ELOOD ZONE APN
pro. y.ameaelusivelyeonwutingwiNlians cmreactors , y. SpXI PI'uMBWG PERMIT,:'^:i•1� ,y,F�may,;
construct The Pntject(Sec.7044,Business and Profauiom Code:)The Contractors
Licerae lawdasnot apply toanownmofproperry whobuildsmimprove.Ncrcon.and PERMIT ISSUANCE
whocmuafmwch projectswith acontracmr(s71iansed ptrmtrantmtheCentamora
License Law, ALTER-DRAIN&V -WATER(EA ;��v,-',<.%:'..*'. j,iFEE SIIMMARYti=
;:.
❑ I am cxcmpt under Sec. ,B&P C for Nis reasonOUTSIDE FEES
BACK FLOW PROTE .DEVICE SANITARY Y N
Owner Due DRAINS-
FLOOR, OO F,AREA,GOND. REC..IFTX
T-+ WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IhNeby effum Netlhnvesceniflcam of conaendmselNinwrt,macenifinre ofRECEIPTM
Workers Compcnsathan luurancemaanified copy Nereo((Sec.3800.Lab C.l which FlXTIBtES-P TRAP PARK FEE YN_
c.versollemployec'sunderdapwnit. GAS- STEM-IINC.40METS RECEIPTX
Policy X BUILDING DIVISION FEES
Company SYSTEM-OVER<(EA PLANCHECK FEE
[jCenified ropy is hereby furnished.
❑ Certified copy is film with the city inspection division. GREASFNJDUSTI LA OT4471FTOR, I GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP BOILS FEE
COMPENSATION INSURANCE
(Dens section nerd not bewmplet difthe pemtit is(Drone hundrMdollan(SI00) SEWER-SANITARY 200 ENERGY FEE
or leas.)
I«nify Nod in the pofom ,tithe work fmwhieh Nis pemtit is issued.I small IeATER TER /E CM
no,employ an,person N anY mannor ha as m became subject m the Workers PAID
Z Compensuionlawsof California. Date TER S TING Data ReeciptX
* Applicator
N0710ETO APPUCANT:If,dormatin,This CeNBcne of Eacmption,you should NE IDENTI MB. SQ. TOTAL;
2
becom,subject on The Workas Co rF nation provision of The Labor Code,you must
forthwith comply with such Mvi.iaw or Ni.pemu,shall W darned revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
jZ Ihereby affirm that there is a ansmmion lendingagrnty for the performance.( TOTAL: ELECTRIC FEE
J O the work for which This permit is issued(Sec.3097,Civ.C.)
Lenders Name }x' - i r y„ PLUMBING FEE
Lenders Address QTY.s''nA CAL PE " "y. ''FEE
J 1 certify that 1 have read Nia application and mite Nat Ne above in(omauan n 'a - � 't- ""_ '"' IL_ "d•-
Scorrect. lag tocomplywidhaicirywdco tyro inwcmmdmmlawsmladngu PERMIT ISSUANCE MECHANICAL FEE
0 Wildin,construction.and hertbyamboriae rerescomtiviceofthi,city do enmrupon the CONSTRUCTION TAX
Z abovemenuoned property for inspection purposes. ALTER OR ADD TO MECH.
(We) ,mom save.indemnify rod keep harmleas the City,of Cupertino eglum,
liabilities,judgmentacostswdexpenuswhich en any wry acem agairrg7idj AIR HANDLING UNIT(TO I0.0))CFMI
in consequentt of Ne,mntin8 of thispmnit. �(�'
,•�!� _` AIR HANDLING IIIT(OVER 10.0414t
Stg wseof Appbcam/Conmmor / Data EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 103,M)BTU) Dam Receipt X
Will the...11cant.,future building occupant lana.,handle hawdous mmnol
as defined by the Cu,mm,Municipal Cade,Chapar 9.12,rod The Health and Safety HEATING UNIT(OVER 1 W.000 BTU) A
Dada,Section 25532(.)?
El Yes El No VENTILATION FAN(SINGLE RESID)
1fidUB
Will thea licanwrfmurc buildin BOIhER-COMP(3HPOR IG7,H00BTU)
N..
PP as The Bay eyuipmem Quality
Management
howdoos air contmitmnm u defined by Nc Bey Area An Quality Manegemcm BOILER-COMP(OVER 100.000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. FEB 24 1095
1 have read the W.dousa
nrtrials requirements under Chapter 6.95 of The
Calif..,.Health&Safety Code.Sections 25505.25533 end 25534. Iundernand NClI I v�
That V set-
if the building does oat currently have a arum,that it i,my responsibility m notify the
cm.,se t of the requiremans which must be met'norm issuance of a Cenifiam of
Occ.'re,
Owmcr or aulhonud agent Dam TOTAL: ISSUED BY:
`
OFFICE