27891APPLICANT TO FILL IN INFORMATION WITHIN RFn I IMee _ I lee 0 A 1 1111.1,11 ne,. In, -
CITY OF CUPERTINO n.mN -
UILUING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
PF:RMITNO.
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IIUILDING I'Hf1JRC'I'IIIEN'fIF11:A'ITON
L VX 9
UILDING ADDRESS: 1 t ®�
/ fhb/
O E S AME7: PHONB:
ri
' ARCH17tiCT/FNGINEER: LIC NO:
AssLKI(.T': PHONE:
UNITx LOTI,
CO 'RACTOR:S AME: C NO:
O
p S;
T6 or eper N e
SANITARY NO.
APPLIC IIONSUBMITALDATE
N/C CONTROL#
❑
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ \j ❑
I'FO
PERMIT ISSUANCE
LICENSED CONTRACTOR'Simis Gf RATIONhaPW9(
(commencing with
LD Iherebyaffinnthn3 amlicensedinss and refieshom Code, and
O fall Section Division 3of Nc Business and Professions Cade, and mylicense is in
full tome and effect.
License Class Lic.is
y Dale Conuactm201
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
TOB DESCRIPTON
Z ARCHITECT'S DECLARATION
O 1 understand my plans shall be used as public records.
- 1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
pSQ_ FT,
SIGNS ELECTRICAL
Lu:ensed Profesnonal
U OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Connectors License Law for the
run following reason, (Section 7031.5, Business and Professions Code: Any city or county
.¢4 which requires a permit to construct, alter, improve, demolish, or repair any structure
pronto its issuance, alsomquims the applicant for such permit teBleaaignedsmlanent
p that he is licensed pussuanuo the provisions of the Continental's License Law (Chap¢,
a 9(commencing with Section 71g0)of Division 3 ofthe Basinessand Professions Code)
n of he is exempt therefrom and the basis for alleged exemption, Any violutionof
Section 7031.5 by any npplicnm fora permit subjects the appliean,oacivil penalty of
., notmom than Ove hundred dollars ($500).
❑ I,asownewfthepropeny.ormyemployees with wagesastheinolecompcnsnion,
will dothe work,and the saucture is not intended oroffcied forae7044, Business 70Business
and Professions Code: The Cnntnscones License Law does not apply on an owner of
properly who builds m improves thereon, and who don, such work himself or dwugh his
own employees, provided that such improvements arcnot intended marooned for sale. If,
however, the building orimprovement is sold within one yearo'completion, the owner-
Isidder will hove the burden or proving that he did not build or improve for puspaxe of
sale.).
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE MST,
POWER DEVICES
SWIMMINGPOOL ELECTRIC
VALUATION
OUTLETS -SWITCHES -FIXTURES
NEWRESIDENTIALELECIR_SQ, FT.
STORIES
OCC. GROUP
'TYPE CONSTRUCTION
RES. UNITS
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
❑ I,asownerofthepmpeny,amexelusivelyconv¢tingwiJlicenx wnvacwrsm
construct the project (Su, 7014, Business and professions Cade:) The Connector's
License Lawdoeirmapply toanownerofproperty whnbuildsorimprovesthewon,and
who contracts for such projuts with a cooractm(s) licensed Pursuanno the Contractor's
License Law.
❑ Inn exempt under sec. , B & P C for Nis mwm
FLOOD ZONE
APN
In
ALTER - DRAIN & VENT- WATER (EA)
PEE SUMMARY
BACK FLOW PROTECT, DEVICE
IDE '1
Owner Date
SANITARY Y N
RECEIVE '#
WORKMAN COMPENSATION DECLARATION
I❑ Thereby nfOrm tier] huveettnificne 0fconsenno tilt -insure, oracenific roof
Workim'Compemation Insurance or a crnified copy thereof(Sev. 38M. Lab C.) inch
"vera all employee's unionbix permit,
DRAINS- FLOOR, ROOF, AREA, COND.
SCHOOL TAX y N
RECEIPT#
RES - PER TRAP
PARK FEC Y N
GAS- .SYSTEM -I ENC.40 rr,-1 �
Policy#
RECEIPT#
Company
GAS-EA.Sy -M-OVER4HA)
BUILDING DIVISION FEES
Cl Cmifiedcopyisherebyfumished.
❑ Certified Copy is riled with the city inspection division.
PIANCHECK FEE
REASEANDUSTRI. TE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORK S'
COMPENSATION INSURANCE
REAse _
SOILS FEE
(This section need not be completed ifthe permit is Toro on d011ars(5100)
or I...)ENERGY
EWER- A - ORM EA. 200177',
FEE
Icertifyihatinthe Ndonnanceoftheworkforwdabs permit is issued. I shall
no employ any person in any drummer so as o 0. subject o Ne W.A.-
Compensation Lowe of Califamia. Dam
Applicant
WATER TERW NT/ELECfR
PAIDW
Date Rueiptp
TING
NOI MaC<nons ofo emDtian,y
NOTICE bj APPLICANT: If. after Compensation
become su comply it sader'a Compensation prmit hall he odq you must
forthwith comply with such provisions or Chia permit shall be deemed rtvo
ESIDENTI PLMB. SQ. FT.
TOTAL:
BUILDING PEE
CONSTRUCTION LENDING AGENCY
I hereby affirm flood 'he. is a construction lending agency for the performance of
the wok for which this permit is issued (Sec. 309], Civ. C.)
landrrs Name
SEISMIC PEG
T T L:
ELECTRIC FEE
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify that I have surd this application and site that the above information is
Correct lonsuasawith all<ityend rounty amirunccn and Bills laws seining to
building construction,
n, and and mb Antituriu mprcsentatives of Nis city Wenter upon the
above-mentioned pr for spection purpos
(We)ngme mo
I fy aid ke mleas the City of Cupertst
ino again
liahilid s,jud n tndrxpens may anywayacaueagains aiJCity
taco c a goof it.
PERMIT ISSUANCE
MECHANICAL FEE
ALTERORADDTOMECH.
AIRHANDUNGUND(TON.WCFM)
CONSTRUCfIONTAX
AIR HANDLING UNIT (OVER 10000 CFM)
Sig arc fAVaicanVContre Done
EXHAUST HOOD(W/DUCT
-
ILIZARDOUSMAT IAM DISCLOSURE
Will the applicant or future building accupant some or handle humorous material
as defined by the Cupertino Municipal GNe, Chapter 9. 12. and the Ihealth and Safety
Code, Sutton 25532(4)2
PAID
Date Receipt of
HEATING UNIT (TO 100,000 BTLI)
HEATING UNIT(OVER IOO," BTU)
TO'TA
VENTILATION FAN (SING LE RMID)
❑Yes CI No
Will tai, co ]mama its as huilding by the ay eyuipmir Quality
hamNt? air rants as defined by the Bay Ams Air QuWiry Managcmcnt
Management
Distridl
BOILER- COMP(3HP OR 100,(gNI BTU)
BOILER -COMP (OVER 100.810 BTU)
MSS}IAWC6ATE
Y'"''' PQaO
yo,s
❑ Yn ❑ No
,(J
APR
NEW RESIDENTIAL MECH.—SQ. FT.
1 have read the haeardous materials requirements under Chapter 6.95 of the
California Hcahh & Safety Code, Sections 25505, 25533 end 25534. 1 undersand that
if the building docs not currently have a tenant, that it is my responsibility to notify one
occupant of the requirement, which must be met prior to issuance of a Certificate of
Occ 'nomy.
198
�'�� 5
U1. LUNtkI
BY:
Owner o, authorized agem Door
TOTAL: ISSUED