27559 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO --- PERMIT NO. 27559 7 ^
y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING,PROJECT'IDENTIFICATTON L
BUILDING pD� 12, cou4Tasr Se A2-//JT�T co � 0 vl� SANITARY NO. APPLICATION SUBMfITAL.DATE
/71e.�//Arg Vr ' /� I �`/ONE:�/ I` L//g1/U(YWOnINTRA�CPOR'S NAM@ LIC NO:
/`U+[' G (A/fLNLS'/ 6 V ov N/C CONTRO p
ARCHITECf/ENGINBER✓ - LICNO: ADDRESS
CONTpcT: PHONE: 1 ?.y 45y BUILDING PERMIT INFO
QTY. o-h ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MF:CH
PERMITISSUANCH El 0El
LICENSED CONTRACTOR'S DECLARATION pPpLIANCPS-RESIDENTIAL TOB DESCRIPTION
pKz Thereby Mail am
DJZLARapter9(cmnmrncingwiN JO
�00 Section700M.Mivism 3afthe Business end Professions Coda and my llama is in PANELS
y.tsE full force and effect.
<zW Licerue Class Lic.p UP TO 200 AMPS
�:D Date Cmasou ms 201-I000 AMPS SQ.FT.FLOOR AREA $6Q.FT.
z00 z; ARCHITECTS DECLARATION OVER 1000 AMPS
0 z-0 1 understand my plans shall be used as public swords.
r y t ui SIGNS ELECTRICAL
<'� J Licensed Professional
y6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
euO y U I hereby affirm Net I sum exempt from the Contractors License Law fm the
F LLr o.]ya following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST,
which m9vims a permit to mmanim,alma improve,demolish.or repair any swctum
Y:p prior to its issuance,also requires the applicant for such peradim fileasignedsmtem ul POWER DEVICES
G that he is license pursuant to the provisions of the Comrwhit's Li.Law(Chapter SWIMMMG POOL ELECTRIC
d.�0 9(commencing with Section 701(1 of Division 3 of Ne Business end Pmfesaions Conic) VALUATION
W_y or Nat he isesemp therefrom end Ne basis for thealkged exemption.Any claim.of OUTLETS-SWITCHES-FIXTURES
f..zY Section'/031.5 by any applicant for ape.iuubjeem the applicant w a civil penalty of
µp❑S n m him five hundred dollars(5500). NEW RPSIDENTLIL ELECTR _SQ.Ff. STORIES TYPE CONSTRUCTION
asownerofthepropeny.ormyemploymwithwagesm Neirwlecompert bus,
d3� Ill dome work,andthe structure isnotiaterded conflicted formic(See 0044,Business
and Professions Code:The Commdm's License Law does not apply m an owner of
property who builds or improves thimmar.and who does such wools himsel f or Nmu gh his
own employces,Inovidedthatsuchimprovemenmart notimettdedmoffewl forsale.If,
OCC.GROUP RPS.UNITS
however,the buildingorimprovement is sold within oneyearofcomplefion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale,).
❑ I,asownerofthcpropeny,amexclusivelyco acting Ilcenscdeamostom to Q,PYI'. .. PLUMBING PERMIT FF.F. FLOOD ZONE APN
construct the project(Sec.]094,Business ofeasiom eJ The Convectors MIGHT ISSUANCE
Licenselswdcesnot vpplytoanownerofp any whobuildsm proves thereon,and
whoconvrcts for such projects wiNeco acma(e)licensed pure mthe Convvcmrs ALTER-DRAIN&VENT-WATER(EA) FGH SUMMARY
License Law.
❑ 1 am exempt under Sea .B&P for this reason BACK FLOW PROTECT.DEVICE O SI
SANITARY Y N
Owner Dam DRAINS-FLOOR.ROOF,AREA,GOND. RECEIPT#
WOR AN COMPENSATON DECLARATION SCHOOLTAX Y N
1C•
roveW9 Ihertby efr t l haves cenifica¢o(consentmaelf-insure.ora 'Ream of FIXTURES.PER TRAP RECEIPI'Y
Workers Comprna on lrLsumnce orecenifiedcopy Nercuf(Sec.3gtg,Lnb which PARK FEE Y N_
is all empl 's undo Nis permit. GAS-EA.SYSTLM-1 INC.40UTLEI'S RECEIPTN
Policy M BUILDING DIVISION FEES
C.I.I. GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FFL'
❑ CeVl�wxC�if..w
ise
.
❑ Ceis ' d' Bion. / GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
ION FROM WORKERS' C GREASETRAP SOILS FEE
IONINSURANCE �j//\
(Te if Ne perenil is fm,one and oll ((100) WER-SANITARY-STORM EA.200FI'. ENERGY FEE
or lase.) \]\Ke�hja
Iaththe workf wh<hN it is issued,lshdl WATER HFA W/VCNT/ELECIR
not empus to ome subject to Ne W _ PAID
Cma,mCdifomia. Date w RSYSTEM fATNG Date Raeiptp
Q z Applicant -
zz 0 NOTICE TO APPLICA lf,afle nu ing this Cenificme of Exem�y' ,you should AL PLMB.—SQ. TOTAL:
V) become subjecuo NeW :crs Compensadon provuiow of the la s(r Code.you must
> rwhwiM comply with sac Provisions m this perm/'Wilusperfornmansof
Wmused. BUILDING FEE
zQ CON UCTION LENDINSEISMIC FEE
1 hereby affimt Net the i onstruction lenELECTRIC FEE
ONe work fur which this permit s issued(Sec. ,
;.enders Name s_ PLUMBING FEF.
Isndcrs Address QTY.C�:;.I' MECHANICAL PERMIT FEE G I certify thus I have aced Nis applicdion and site that the above information is MECHANICAL FEE
conal lagrato comply with dl city said cowtymdiwnces andetate laws relating% PERMITISSUANCE
F-' building conavuaion,and hereby matimire repteeentndveaofthis city to enter upon Ne CONSTRUCTION TAX
(� 7 move nummned property fm inspection puryoses ALTERORADDTOMECH.
O (We)agree to save,indemnify and keep harmless Ne City of Cupertino against
hatelitim,E aero,ensu and expenses which mryin any way acerueagaimtaaid City AIR HANDLING UNIT(TO 10,000 CFM)
in cn sof Ne granting ofibis pcami.
AIR HANDLING UNIT(OVER 10,IX01 CIM)
Signatu •of Applicant/Contmmm 1/ / 11 Deter EXHAUST BODO(W/DUCI) PAID
I A RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt p
Will the applicant or future building occupant store or hatMle hazardous mncrid HEATING UNIT(OVER 100,000 BTU) TO
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Cade,Section 25532(,)4
El Ycs 1:1 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicwlorfutumbuildingoavpantunp uipmentardevices whichemh BOILER-COMP(311P OR 1(10,(100 BTU)
hazmdom air co usurnmenb as dcftned by the Bey Ams Ab Quality Management BOILER.COMP(OVER IOLOX)BTU)
District? 13 Ye,' 11No NEW RESIDENTIAL MECH. SQ.PT. I"PA I D
P have read the hamrdous materiels requirements under Chapter 6.95 of Ne
Cnlifomiallealth&Safety Code,Satiuns25505,25533and25534. lundnismadthat
it the building does not carmn0y have a tenant,that it ie my responsibilityto notify the
occupant of the tequirmandu which must be met prior tp issuance of a Certiftcthe of
Occupancy.
L
Owner m authorised agent Date TOTAL: ISSUED BY:
OFFICE1