27817 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IsUILVINts- ' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n J Q
BUILDING DIVISION BUILDING PROJEC'1IDENT1FICA'1']ON G I o
BUILDING ADDRESS: SANITARYNO. APPLICATIONSUBMIITALDATE
O1 xn OA P'd UNITN LOT# S-�r-vr
NTiRS NAMI?: PHONE: _I CO ACIV) 'S NAME: IC NO: N/C CONTROLN
ARC! TECI' GINEFR: In if�o, LIC NO: (�'/IA ADDRESS
Ave. Aced.
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
Kac qj5 —tl �� q '�)� &e BLDG ELECT PLUMB MECH
y .Y•� PERMIT ISSUANCE �- mil fVl
LICENSEDCO ACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL .•�`�` VJ 110Cg�DFSCRIPI'ION
GZZ I hertbymifirm that l am licensed underprovisionsofChapter9(cammencing with
�00 Section I0W)if Division 3 ofthe Business and Professions Carle,and my license is in PANELS
r{W full Oerceund effect./
a'yV'y License las I(� Lic.N 3365 UPTO200AMPS
r~n?y Date -io—��' Contac,., 201-IOW AMPS. �' J V`�
1p- Za ARCHDEC'pS DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
O Z^❑ I undemm�d my plans shall uused m public recoMsAMPS
. OVER 1000
ra�4j SIGNS ELECTRICAL
.J Licensed Professional a
P'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUrGMISC.
ippi55,,O a U I hereby affirm that 1 am ve
exempt from the Contractors License Law for the
ec :4y following reason,(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
ce which requires v permit to construct,alter,improve•demolish,or m*r any smactum
Y`�Y� prior w its issuance,also"iirea the Will..fm suchpamite.fuleasignedememmt POWER DEVICES
W Kq 00 that he is licensed pursuant o the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
see 9(commencing with Section 0000)of Division 3 of the Business and Professions Code) VALUATION
Warn or that he is exempt therefrom and the basis for the alleged exemption.Any violation of
F-ZQ Section 7031.5 by any applicant for v .it sub'au the licum w a civil OUTLETS pe ) pp penalty of 0I] nen more then five hundred dollars(5500). /-00 moo
C3 I...... NEW
-0NEW RFSIDENTIALELECTR _SQ.FT. TRIES TYPECONSTRUCIION
❑ olhe wnaMtheassamm,ormyemp.oyeeawithwegeas theirs...0,PL Buation,
p, willdoth¢work,ande: hemureienot's License
Law offemil
not.apply to an Easiness
and ery,who
ore Code:The Ces t erten.License Lew doh not apply if an owner iof
s
ow n ertyloyees rovidmprovesch such unprovndwhodnemch work or offered
Ms 60C GROUP RES.UNITS
veneer,thebuping or improvemenprovementsin neyot earcdedo pletiod the owne.If,
however,thebuildingburden ofemem iesodwithinot build of completion,Nrpose of TOTAL: 3)l Qp
builder will have the burden of proving that he did not build m improve For purpose of
, teal.
❑ I,uowner.fiMpmpeny.ameaclusive.yc.ntmctingwiNlicensedc.nr ,amw QTY. PLUMB PERMIT FEE FLOOD ZONE APN
consumer the pmjcct(Sec.70i44,Business and Professions Code:)The Contractors
L,enae Law does not apply to an owner ofpr.perty who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such pmjecu with a convector(s)licensed pursuant the Commences ALTER ATER FEE SUMMARY
License Law. (EA)
❑ 1 am exempt under Sec. ,B&P C for this reas.n BACK FLOW PROTECT'.DE SID
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,ARFA, RECEIPT#
WORKMAN COMPFNSATIONLARA
DECTION SCHOOL TAX Y N
❑ Ihemby 0(fimt thaU have acenifwauof consenuo reif-insert.orecenificate of FIXTURES-PER TRAP RECEIPfN
WorkersCompensation insurance ora certified copy thereof(Sec.3800,Lab C.)which PARK FEE Y N_
coven all empl.yee'e under this permit G A.SYSTE - C.4 OUTLETS RECEIPT'N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER
❑ Cenified copy is hereby fum idnA. 3 PIANCHF.CK FEE
❑ Cenified copy is filed with the city inspection division. GREV%VINDUSTRL WASTE IN CEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(nisaectionneednorbecomp.etedifthepermitisforonehundreddollars 100) SEWER-SANITAR -STORM FA.200F\ ENERGY FEE
.r less.)
Icenify that inthe peffomtenceofdte workforwhichthis Permit isissu ImMI WAT fHFrXTENT/ELEEP
not employ any person in any manner so to become a b' t w the .ken' PAM
7-. ComperuerionI sof Ca'fomi Daw �— WA YS N Date RaeiptM
APPlicunt
NOTICE TOA PLICANT:If,after mak ng this Catifht of Exemption,y. shouldV IV R NT'
_SQ
TOTAL:
(•' .�. become subjxtwtM Workers Compenseti.n proviaiore ofmhe Labor=,, umust
a > forthwith comply with such provisions or this permit ah all be deemed cevoked. BUILDING FEE
DJ �] CONSTRUCTION LENDING AGENCY SEISMIC EEE
Thereby affirm thenherc isawewction leMing agency Tonere perform cof TOTAL: ELECTRIC FEE 90
(❑ O the work for which this permit is issued(sm.3im.Civ.C.) 33 OL
Lender's theme
P
O V Leader s Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have red this application sam ion end¢dime rhat an above information is
building construction,
onte won,complyand whh01 yatmorie eounryotdinenceaand saw laws rt.atingw PERMIT ISSUANCE MECHANICAL FEE
U y almocngcoforcul.nand hercbyauthodu mprees, of Nis city roamer upon the CONSTRUCHONTAX
L) z uhoveWe)igree propertyfor inspection purposes. ALTER OR ADD TO MECH.
We)agree to save,indemnify and keep hashar the City of OUPenino against
liabilitie,judgmcnu,roar expense which expwhich may,in any way accmeegalnst sad City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of the granting of this i
AIR HANDLING UNIT(OVER 10,000 CFM)
W .P. 3-20-9s
Sigat:ure of APPlicam/Commct r Date EXHAUSTHOOD(W/DUCD
PAID !e KS9l�
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt N
Willthenppliclm.,future building or....main.or handle hazard..material /�� C/o
defined by the Cupenino Municipal Cede,Chapter 9.12,and the Health and Safety HEATING UNIT(OV EB I00,00D BTU) TOTAL:
Code.Section 25332(a)?
❑Yes ;<No D)VENTILATION FAN(SINGLE REM
BOILER-COMP(311P OR IM.W BTU) � ISSUANCE DATE
Will co ihmm is as defined b c the Bay A uipmir Quality
P A p-k
Membe.ua air conmminanta u defined by the Bay Arca Air Quality Menvgemem BOILER-COMP(OVER 100,000 BTU) V
D'suicm? ��
❑Yea NN. W P NEW RESIDENTIAL MECH.—SQ.FT. MAY
34),995
1 have read the hazardous materials r rimmed under Chapter 6.95 of the MA
California lidth R Safety Cede,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the r�
occupem.f the requirement which must he t9ct'nn t.issuance of n Certificate of Ci I Y VI I IIVV
Gccupuncy. 1Q e
Owner or eu udagem � Date TOTAL: ISSUED BY:J 0� i�JN7.atkt,,,cef
OFFIC