27873 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .;NU- PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n
BUILDING DIVISION BUILDING PROJECT IDENT'IFICA'TION L 1 7 0 7
O I
BUILDING ADDRESS: /'/� �/�.� /� SANITARY NO. A2PPLICA�TIONn�SUBMITTN.DAIE
220-.5' a&4?k a. UNIT LOT# y
OWNERS NAMF,: PHONE: CONTRACTOR'S NAME: LIC NO: / V
bhC COM'ROL#
ARCHIfEC(ENGINEER: LIC NO: ADDRESS:
• 13CONTACT: PHONE: k'55'r.a:nS ad'w -x �':$(e `6UIL�ING PERMIT INFO
Q�T�Y 't4r" EGTRI PERMpIT_.`; .FEE ..
wBLDG ELECT PLUMB MECH
PERMIT ISSUANCE ^ 1
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB
nf sewz Ihereby afthat l am licenunderprovisionsofaapler9(commencingwith
LuLOB DESCRIPTION
FOO Section 70(10)of Division 3 of the Business and Profession Cade,and my license is in PANELS
yU5 fallforceCand CBect. UPT0200AMN
GFUZm Date Clues Como 1 • ! a V
=y Dae ComrSD I01-IOOOAMPS
z U r. ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLOOR AREA EISQ.FT.
02—0 I understand my plans shall be used as public records.
POtb� SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIALCIRCUITIMISC.
s•Opm,U I hereby affirm that I am exempt from the Contractor's License Lew for the
W H following mason.(Section 70313.Business and ssions Code:Any city or county TEMP.MITHER OR POLE INST.
F-� which requires a permit to construct,alact, ve, lish,or repair any structure
W>� prior to its issuance,also requires the atforsuch motto figned ES
le esistatement POWER DEVICES
p thmt he is licensed pormen 1.the p stun sof the Cana tors Li..Law(C7h pier SWIMMING POOL ELECTRIC VALUATION
aao�' 9(cornmencingwith Section? ofDivision3ofineB fines end Profevsiom Cade)
,:2w or that heisexemptthotcf andthebasisforthealleged xemption.Any violation of
5,rG Section 7071.5 by an lican firr.'ndsubjectsthev licannoacivilpeneltyof )OUTLETS-SWITCHES-FIXTURES
NO
am more than n, ndred dollars($500).
NNEW RESIDENTIAL ELECfR SQPT
CSO ❑ bety
baso rofthepeop .ormyemploycoswimwages theirsolecom _ . .
ue
pertion, STORIES TYPECONSTRUCION
y3— willdo work,audthcsbuctureis not inteMedoroffemsift a(Sec.70x4.Business
and ofessions Cade:no Contractors license law does t apply to an owner of
pro who Wildsmimptovesihemon,andwhodocisuchw himselforthmughhis
own mployeas,pr.vidWtha"s himMvc=nts= mtinwn doroffcredfaxsla If, OCC.GROUP RES.UNITS
how e,.th.1mildingmirnprovemoti. Id i e ompletion,Neowner- T
buil rwillhavethebmdenofpr ving t _ ild or reprove for purpose of
sale) QTY, °PLUMBINGPERMIT FEE" F1.00D ZONE APN
❑ wnerof lh velyconsectc
in uedntre
coctom to
cons d the 're _ y muses and Pmf s Code:)The Contractors
Licens Isgdoee
It pIII anowoerofprope obuildsmfimpmvesdaemand PERMIT ISSUANCE
whore ttactsfmmch m tswithaconw s)licensed pmauent to the Combustors ALTER-GRAIN&VGENT-WATER
Lice. Law. (' ) FEE SUMMARY
❑ 1 camfo under Sec. ,B di P C for Nis naso BACK FLOW PROTECT.DEVICE OUTS[U ISE
SANITARY Y_N
Owner Date RECEIFT#
DRAINS-FLOOR,ROOF,AREA,COND.
MAN COMPf;NSATION DECLARATION SCHOOL TAX Y N
❑ Ih imt Nat l have.comficawmi'mnsem to self-imme.ora certificateof FIXTURES-PER TRAP RECEIPT#
Workers' mrematinn lnuraaeora certifiedcopy Hereof(Sa.3800,1ab CJ which PARK FEE Y N
covers all employee's un der this pcmait. GAS-EA.SYSTUM-I INC.40SfD.EPS RECF #
Policy# BUILDINGD ISION FEES
Company GAS-EA.S (EA) PLANCHECK FEL
❑ Cenifted copy is hereby famished.
❑ Certified copy is Glad with the city iturcroon division. Q RPAS6NDUSTRL WAST CEPTOR ', GRADING FE
rf
CERTIFICATE OF EXEMPTION FROM WORKERS',r, "° OREAMiUr, In SOILS M
isd
COMPENSATION INSURANCE
(Thissectionneed not be completed ifthe permit is frronehundrad dollars($100) 'I, S R AfrIT FT. (. EN' Y E
or Ices.) k�
(unify that in the Performance of the work lmwhich NisperWit is issued, l' •A R IV
not employ my person in any or w as to become mblc l'to the W / PAID
CmItromaaion Iews of Cdifomia Date y A YSTE - Oate Receipt#
0 ,z Applicant
0 NOTICE TO APPLICANT:IL aper staking this Certificate mf Exemption,you All WR AL PLMB. - ^'SQ.FT. TAC:
LI) become subjet to the Worker's Compensation provision of the Labor Coda you must JmP.,-
forthwith comply with such provisions or this Formal sail Na demur revoked. 0 �..p. BNLDI F.E
L+a [] CONSTRUCTION LENDING AGENCY }� U -.sz_3sN"'v SEISMIC FE
z Ihereby affirm that there is a ormsomdon lending agency for the per07ance of
U 0 the work for which Nis petrut is issued(Sec.3097.Civ.C.) ...v„•' TOTAL: ELECTRIC FEE
Landers Name
u-' Lenders Addrus QTY. MECHANICALPERM1T " FEE - PLUMBING FEE
0 U 1 certify tMl I have reed Nis application end sme that the above information is
W cosrm.l agree to marry with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
I-" y buildiagcommucuon.end hereby authorize representativesofthis city toenter upon the CONSTRUCTION TA
U - hand property for inspection purposes. ALTER OR ADD TO MUCH.
(We7 e m save,i dernnify and keep herMeas the City of Cupertino against
abilities,jud encs, amdexpameawhich may anyway a agaiwtsaid City AIR HANDLING UNITITO 10,000CF)
sequence ft ting or,
it.
�b9 AIR HANDLING UNIT(OVER IO,gMI CFM)
SiH D EXHAUST HOOD(W/DUCD re PAIDmDOUg MATMIALS
DISCLOSURE HEATING UNIT(TO 100,00)BTU) Date Ru pt#
Williheappiicam rraw.building o .W,same or handle hazalloue mvn
e0
as defined by the Cupom o Municipal Code.Chapter 9.13,and me Health and Safety HEATING UNIT(OVER 100,000 BTU)
Cale,Section 25533(.)4
❑Yes 13 No VENTILATION FAN(SINGLE RISID)
ISSUANCE DATE
Will Nevpplicammrfulumbuildingoecupant usecquipmentordeviaawhichemit
BOILER.COMP(3HP OR 100,000 BTU)
• harardous air cormarmane as defined by the Bay Arco Air Quality Management BOILER-COMP(OVER 100,001 BTU)
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. p
10 1 have read the bmallom materials re,.ircmcnts under Chapter 6.95 of the e,'1
Celifomia BealthffiSafety Coda,SCctiom 25505,25533 end 75534.Imadenompto qtj 2
if the building does not currently have a tenant,that it is my responsibility to notify Ne e,1
occupant of the requirements which must be mea priorm III. a of a Cmificvm
Occupancy.
Owner or authorized ager Dam 'I Ol'AL: ISSUED BY: