27991 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINODINirEL' PERMIT NO
BUILDING DIVISION .
APPLICATIONIPERMIT PLUMBING-MECHANICAL. 27991
RIIILOINC,PROJEC9'IDENTIFICATION
B UILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL
DATE-
LOT#
ATE-
LOT#
NP S AME: PII NE: CONTRACTOR'S NAME: LIC NO: N/C CONTROLN ,J
o(a
CHITECT/ENGINEER: LIC NO: ADDRESS: ❑ /I
CONTACT. PHONE: BUILDING P/\EORMIT[NFO
Z201.
ELECTRIC PERMIT FEE
E PLUM Cf
IT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION IANCES-RESIDENTIAL LOB DES PITON
❑eez lhenbyaffumthatie tionedunderpmvisimsefC apter9(commandnewiN
f400 Section]MIO)of Division 3 of Ne Busimae and Pmfessmns Crabs,and my Dcense is inELS
HC V full force and effect.
F W License Clasa Lic.# 0200AMP5 24)
rut as Date Contractor. IOOOAMM rimZ.OyzZ ARCHITECT'S DECLARATION R Hall MPS SQ.FT.FLOOR AREA $/SQ.FT.
O2.-, I understand my plans shall be used as public rmords.
f=,y, -j SIGNS ELECTRICAL _F k ,0 Lensed professionalF`Z`IF I#
yyCW< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. /7 ,s iaa O�
cd O y U I hereby affirm that 1 am exempt from Ne Contractor's License Law for Ne v �//V� (V�#
0 5t
W 3 LL" following mason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
ES 0y which requires a permit to construct,eJim,improve,demolish,armfuls any structure
M}� prior to its issuance,also requires Ne applicant for such petWt to file a signed statement FEWER DEVICES
GC) that he is licensed lationcom 90 the Provisions of Ne Contnmoh License law(Chapter
4 e 9(commencing with Secuon]000)of Division 3ofthe Business and Profession Cade) SWIMMING POOL ELECTRIC VALUATION
❑y SeNmheie exempt Nerefrom and the bnist subject.the
exemption, civiny l olation
of OUTLETS-SWITCHES-FIXTURES
G Section] JLS by any applicant(orepcmrit aubjene the applicanno ecivil penalty of
nut Nan five hundred dollars(5500). NEW RESIDENTIAL ELECTS S L
C o 1.esawnernDheproperty,armyemploymswithwagesntheirsolecompenation, O�PC STORIES TYPECONSTRUCION
pW,D; willthe work,end the motion,is not intended or offered for We(Sm.]044,Business
end ns Code:The Convector's License Law does not apply to an owner of
praperty,who builds orimprown thermn,and whodoes such work himselfordirrugh Ns
own employees,provided Notsuch improvements mrenoimended oroffered fosale.If, QC]�C GROUP RPS.UNITS
however,Ne buildingor improvement is sold withinoneyeerofcompledon,Neowner- TO L: 'G•
builder will have the burden of moving Nat he did not build or improve for purpose of
wle.).
❑ I,as owneroftheproperty,amexclusively contracting with licensed contractors to QTY' PLUMBING PERMIT FEE F1.00DZONE APN
construct the project(Sec.7044,Business and Professimu Cade:)The Contnetor's
Licenselawdoesnotemlyto un mwnerofproperty whmbuilds Or improvesthereon,and T
PFRMITISSUANCE
who contracts farsuch projects with acantou4or(e)IicensW pursuant to the Convector's 46
WATER(LA) FEE SUMMARY
License law. ALTER-DRAIN&VENT-
❑ 1 am exempt under Sec. ,B&P C for this xenon BACK FLOW PROTECT.DEVICE SANITARY y 0UTffffffrFFq_
N_
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECETPf#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
re Ih<rebyn rm thntlhaveeaniFicete mfonxnt to ulf-insureora cenifiote FIXTURES PER TRAP C'EIPT#
ahen'Compensation Insurance or aceniled copy tharmf(So.38'WLab C.)wIt hich PARK FEE N
covers all employee's ander this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS # s
Policy# BUIUPW DrJAION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKF
❑ Certified copy is filed with the city inpection division. GREASE/INDUSTRL WASTE INTERCEPTOR
GRADIN E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS
COMPENSATION INSURANCE
(This section nem not becoupleted if Ne permit is for tate hundred dollen(5100) SEWER-SANITARY-STORM EA.200FT. ENERGYQ
or las.)
I certify Nat in Ne perfurwmeofthe work fm which this permit is issued,Inhall WATER HEATER W/VENT/ELECIR
no employ any person in any manner so as to become subject to Ne Workers' PAID ��
Conpemwtioa Tawnof California. Dow WATER SYSI'EM/TREATING Dote
O z Applicant
z 0 NOTICE TO APPLICANT.If.atm making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. a TOTAL:
V? become subject to Ne Watke/s Compenation provisions of the Labor Code,you must
� ; forthwith comply with such Provisions m this petWt shell be domed revoker. BUILDING FEE
O CONSTRUCTION LENDING AGENCY SEISMIC O
I hereby tiff Met hem is a construction lending agency for the performance of
Ne work fm which this pemdt is issued(Sec.309],Civ,C.) �� ELE 1 FEE
Lenders Name
U 4ndels Address QTY. MECHANICAL PERMIT FEE PLO E
1 certify that 1 have and this application and state that Ne above information is
W correct.I agree to comply with all city am county uncommon and stain laws mladng to PERMIT ISSUANCE MECFIANIL
buildingconswmion,and hereby organize repmsenmives of thio city insider upon the - CONSTRUCTIO
V z move-mentioned property for inspectian purposes. ALTER OR ADD TO WED.
(We)agree Insane,indemnify and keep harmless Ne City of Cupertino against
~ incomes,judgmenta,wsts mrM<xpen c Mty4VY ycme� taoid C�tr AIR HANDLING UNIT(TO 10,OW CFM)
incnmsequ (the granting ex en t (/1� oill1]-'/\J
AIR HANDLING UNIT(OVER IO,WOCFM)
Sigalure ofA D.T. EXHAUST HOOD(W UCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HRATINGUNIT(T .160,0001ITU) Dote Receipp
Will theapplicanrarfumre building occupent atcmorhundle broom us mmtentil
n ino HEATING UNIT(OVER 100,000 BTU) AL:defined by the Cupor Municipal Code.Chapter 9.12,and Ne Health and Safety
Cade,Sermon e)T
❑Yes,
0 N
VENTILATION FAN(SINGER RESID)
Will the applicanmrfmure huildingocupanmxequipmemordeviceswhichemit BOILER-COMP(3HP OR IIp,0000TU)
ISSUANCE DATE
Nk mdous air cement inams as deputed by the Bay Area Air Quality Management BOILER-COMP(OVER❑ 100,000 BTU) {�,
isms"? /k
Yee ❑No NEW RESIDENTIAL MECH. SQ.FT. a�
I have read the hazardous materials requirements under Chapter 6.95 of the /�� H`�(fy//
! California Death th&Safety Code,Sections 25505,25533 and 25534. I understand Na[ is `(
if Nebuildingdos nal curently haveutenan4thin it ie my responsibility to notify the Y
occupant of the requirements which must k ton prim to issuance of a Certificate of Gh
Occupancy.
Owner ora dimired agent Date A ISSUED BY:
I OFFIC