27811 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY
CITY OF CUPERTINO m' ' A& PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMRING-MECHANICAL ��O'I 'I
BUILDING PROJECT IDEN'TIF'ICA'1'ION o 11
BUILDING ADDRCSS: =Rob
^^ SANITARY NO. APPLICATION
SUBMITTAL DATE
=Rob �*JN IT# LOT# 3-`/
OW PHONE: CONT CfO � � LI NO: .! 6TTR
C N/C CONfROI,p
DITECUENGINEER: LIC NO:jFPADD ESS: N ✓�<e. 11CONTACT: PHONE: +•; r •-) BUILDING PERMIT INFO
QTY T`- ELECTRIC,PERMIT FEE ��CM
ANC L � PLUM
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALDESCRIPTION
M=Z Iherebyaffim that l am liceruedunderpmvisionsofCheper 9(commenting with
11100 Section 71)(0)of Division 3 fthe Business and Professiom Code.and my li...is in PANELS
gdu full force and effect.
FZ, License Clnss Uc.# UPTO200AMPS #
to<ti Date Contractor 201-1000 AMPS
Z O h Z .[ItCFI S DECLARATIO OVER 1(X10 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
0 Z,Q 1 understand y plans shall be used ss pat m records.
re,Y uu1l SIGNS ELECTRICAL
6 C Licensed Pro ss coal
a
OW
OW
ER DECLA T10N SPECIAL CIRCUIT/MISC.
pxx'OyF I retry affirm tet 1 um a one a m' I..Law for Ne
W 3 o fall mg reason.(Station 031 5, u s eaC e:Any city or county TEMP.METER OR POLE MIST.
�fSyn w chrer-reaepermitm c,slier,ion W, r repair anyatnetare
�W>7 Pr r m its issuence,alsoayu s ea ouch rmiu Bleeaignadstatement POWER DEVICES
Q 0 t the is licenud puna t he t of the neem) License Law(Chapter
9 comm f i on3 the Busines and Profession Cade) SWIMMING POOL ELECTRIC VALUATION
❑,� t it. 'a i, th aAlte is for eallegedexe prion.Aivivl,ation of �EyS-SWITCHES-FIXTURES a►� �#a�/a� �r
tion 1.5 nYn li' t epemi ublecu the apPli tmecivil penalty of WQ
� < tmc ehund Jo (5500 - NEWRFSIDENTIALELECTR —SQ.FT. STOkltis `+"TYPECONSTRUCOON
C 1, he fthepropery,ormy pioye a'Nwagaa.th irsolemmperssatum,
a3— Ildot w rk, nd thcsmct re 'nl fmsal Sec.7044.Busimsa
Pro s :The L se Law does no ly to an owner of
try hubuit crit ,andulu doesim orkhi selfomhroughhis
own oyees, 'd t v tmprovemems tintendedo offeretfbr.le.If, OCC.GROUP RLS.UNITS
howe he16aR tpavement is sold in ma,year ofcompletion.the owner.
buildcrwnot Proving a did rot build or improve far Patric.of
nab.). u e QTY. PLUMBING PERMIT FEE Fl.00D ZONE APN
❑ I,as wneroft propcn exclusively commning wird lianxd conu.[msto
corovaet c project(Sac 4,Business and Professions Cale:)The Conumbr'I
m
Licml.a duesnot ymmownerofpropanywhobuildsorimprovestharcon,endPERMIT ISSUANCE,
whmconm for projecn witheconVucmr(a)Iittnsrq punuannothe Conuacbr's
License Law. ALTER-DRATN ffi VENT-WATER(FA) FEE SUMMARY
(] 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE -60TsI5EFEF
SANITARY Y N
Owner Date RECEIPT'#
DRAINS-F100R,ROOF,AREA.COND.
'� WORKMAN COMPENSATION DECLARATION —60
SCHOOL TAX V
I hereby uffirm that l have.cerificam of consent tr.i6inzure,ma cenifimteof FlXTURES-PER TRAP RECF.IPr#
hers Compensation lnsuranceoru«nifedcopy Mermf(Bac.38M.Lab C.)whichPARK FEE Y N
rsall employ k OAS-FA.SYSTEM.)INC.4OUTLETS RECGT p
Pin ey MR. B IV FEES
Company
CeniOed copy is thereby umish d. GAS-EA.SYSTEM-OVER 4 HLA) PLANCHECK FEE
❑
JV,iC&ified copy is filed with Ne city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADIN
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOIL
COMPENSATION INSURANCE•
Cnis section need not be completed ifthe permit is foronehundred dollars($IW) SEWER-SANITARY-STORM EA.2MFT. ENER
or less.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/F.I.ECIR
not employ any person in any manner.as to become subject m dm Workers' PAID
Z Compatio
ensn Lawsof Califomiaece
. Date WATER SYSTEM/IREATINO Dm Ript#
Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
�ato became subject to Ne Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this pcmdt shall be dimmed revoked. BUILDING --y
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FE
1 hereby affirm that there is a construction lending agency forte performance of
U 0 the work for which this pc,u- yRQ(Sec.3097,Civ.C.) L ELECTRIC
Fit
Lenders Name /e ke
QLnulers Address QTY.',"(.,. MECHANICAL PERMIT FEE PLUMBING
I certify Nat I have mad Ms application and sere that the above information is MECHANICAL
>" W r.me,Infirm to comply withal)city east county ordimnces and state laws minting to ` PERMIT ISSUANCE. Ivy
t. y buildingconstmction,and hereby iuthorizempmsenatves milds city to anter upon Me O CONSTRUCTION TAX
U above-camamned,raNny for im,cction purp,mes, ALTERORADDTOMECH.
(We)eg.c t mnify tad keep hartnlus the City of Cupertino M-..,-.
liabilities,' ems,coaa expenses ch may many wayacene against said City AIR HANDLING UNIT(TO Iq,IXp CFM)
in cons ence of 17 g ng of mit.
AIR HANDLING UNIT(OVER 10.000 CFM)
S lure dAppli VComm�or a EXHAUST HOOD(W/DUCI) PAID
HA'LARUOUS MATERIALS DISCLOSURE.
HEATING UNIT(TO IOOdXKI BTU) Da. eceipt#
Wil teappllcunt nr Name building occupant store or handle hazardous material HEA TING UNIT(OVER HKIOMBTU) T
its defined by the Cupertino Municipal Cad,Chaps 9.12,and the Ilmlth and Safety
Code,Section 25532(.))
11 Yes 13 No TIVENLATION PAN(SINGLE RESID)
ISSUAN E DATE
Will the opplicvntmfumrebuilding acupensuxequrnmvicea
ipmrdewhichemit BOILER-COMP(JHPOR 100,000 BTU)
Nous air camaminums as defined by the Bay Area Air Quality Management - BOILER.COMP(OVER IMAW BTU)
sty A f �
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. ryg/e
I have read the hnvudous materials requirements under Chapter 6.95 of the •.!_•� Q�
California I1ea1N&SafetyCade,Sections 25505,25533 end 25534. I undersand Nat Fj
if the building dues not currently have a tenant,that it is my responsibility in notify the
mcupmt of the.qui¢mencs which must be met prim to issuance of a Certificate of
Occupancy.
Owher m.mho fioM"m Data ISSUED BY: O
OFFICE