27796As
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPESION NO APPLICATION/PERMIT PLUMBING -MECHM]CAL
BUILDING DIVISION
PERMIT NO.
27796
BUILDING PROJECT IDENTIFICATION, r
BUILDING ADDRESS:
L ONaL/� tif/� UNJI LOT is
SANITARY NO.
APPLICATION
PLICAA IO�NJSUBywMRTTETAAJ_ DA
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ARCHITECT/ENGINELR: LIC NO:
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rAPwrvrAx6A&w SALATM0%
ONTACT: PHONE:
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QTY :?++�. ELECTRIC PERMII't;;,..."v 'F z -fi
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•{. �;'BUB.DING PERMIT INFO- '.7.
BLDG ELECT PLUMB MECH
•CI 1:1 0 o
LF
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Net 1 am licensed underprnvlxions of Chapmr9(commcneing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
I Section 700p)of Division3 ofthe Business and Professions Code. and my liecom is in
force e and effm.
j License Class Lic.#
Data Con ramor
PANELS
I1PTO200 AMPS
301 1000
ARCHITECTS DECLARATION
I understand my plans shall he used as public records.
3
- AMPS
SQ. FT. FLOOR AREA
$ISQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
SPECIAL CIRCUIT/MISC.
OWNER,BUILDER DECLARATION
1
1 hereby, efrm that I am exempt from the Contracmrs License law, for the
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING ELECTRIC
following reason. (Section 7031.5. Business and Professions Code: My city or county
1 which requires a permit to comtruc6 -Iter, improve, demolish, or repair any suucmm
Rim an its issuance, also requires the applicant for such Permit to file a signed statement
j that he is licensed pursuant to the provision of Ne Contractors License Law (Chapter
• mftiheendngwith Section7000)A10me Division 3ofthe Business and Prokuions Code)
orttutheisexempt therefrom-ndNebssisfor NedlegedexemptionAnyvioladonof
Section 7031.5 by arty applicant for a permit subjects the-pplicar, 10 a civil penalty ofO
I vat�ON
6
S- SWITCHES -FlXTl1 RE$
nme N
ed Man five hundred dollars ($500).
NEWRESIDENTIALELECIR SQ.FT.
❑ LazownerofNeproperry, ormyemploycexwithw-gesas Neinolecom n
will do Newm1k, andthe moctme isnot inbodedmoffered formle(Sec. ,Business
and Professions Code: The Cammucar's Litmoc Law does not app man owner of
propertywhobuilds-Ii-p eslheRon.nndwhodoessuchworkhl sclfmthroughhis
o mployees,pmvidMNatsuchimMvememsmenatintendcd offered(orsale.lf,
however, the building orimprovoment is sold withmone yen ofco pletioatheowner.
builder will have Ne burden of proving that he did not build or im rave for purpose of
saleJ'
❑ I.ss ownerof the property, -m exclusivelYconv-MngwiN lie canuactortt
coruuum the project (Sm. 7044, Business and Professions Code: The Commune.
License lawdoesnotapply manownerofproperty who buildsorimp vesthercmt,and
STORIES
OCC. GROUP
FLOOD ZONE
TYPECONSTRUCTION
RES. UNITS
-
APN
TOT L:
Qom.• _ "•TMf�mwO ,,;,a, ,g�l.;g w";;' ay,•[r s. ..,•
_.
IS ANCE
whocontnctaforsuchprojecds wird-contrenorUllicrnsW purtuend to eContrector's
License
cLew.
❑ I am exempt under Su. , B A, P C fit is Meson
TER -D VENT
-
FEE SUMIv1ARYt2,'
OUTS -D
r s
.,,
ACK FLOW PROTECT. DEVICE
SANITARY Y N
Owner
Due -
WORKMAN COMPENSATION DECLARATION
❑ Ihemby effum Natl haveaartificne ofcoru:em to self-inxure.ma«rdfic to of
Workem Compensation lnumnce macertiBM c opy Hereof (Sa.3800,1ab CJw 'ch
covers all employee's under this permit
Policy #
DRAINS - FLOOR. ROOF, A ,COND.
RECEIPT
SCHOOL TAX Y N
RECEIPT#
FIXTURES - PER TRAP
PARK FEE Y N
RECEIPT#
GAS -EA. SYS -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company11Ca
GAS - STEM-OVER4GIA)
PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cerified copy is filed with the city inspection division.
GREASE/MDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS FEE
(This section need not be completed ifthe Permit is foronehundred dollars($100)
to less.)
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
Icertify that in the pertornance of the work for which this Permit is issue, I shall
o Nation California.
Olinany K many maser so u to become subject a the Worker%
WATER HEATER WIVENTELECfR
WATER SYSTEM/IREATMG
PAID
Date Receipt#
NOTICE TO L :If s tut prion, you should
become Subjectto the Workers Compensation provisions of the laborCode, you must
foMwb), comply with such provisions m this pemtit shall be deemed mvoked.
NEW RESIDENTIAL PLMB, SQ. FT.
TOT L:
BUILDING FEE
CONSTRUCTION LENDING AGENCY
SEISMIC EEE
1 hereby W. that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ C)
TOTAL
ELECTRIC EEE
Lendeh Name
Landers AddressMECHAMCALPERMIT.P
t-� '"`FEE
- ?w"•w^''^''4 ' u" ""^' ° !
PLUMBING FEE
L car fy Nm L have Mad this application and sum that rdmove ove informmion is
PERMIT ISSUANCE
MECHANICAL FEE
sect. l agree to comply with all city and county urdirances and state laws reading to
building construction, and hereby amhodx representatives of Nis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
IRNI.t.....dgm s.msusand expMmses which may in arty way accrue againatsaid City
in. n. of gr.ntin6 of unit.
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.O00CFM)
CONSTRUCTION TAX
AIR HANDLING UNIT (OVER IRM CFM)
' .I
EXHAUST HOOD(W/DUCD
PAID
ignw picanV Date
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dade Receipt
Will the applicant or future building occupant Marc or handle haaardous material
as defined by the Cupertino Municipal Cee, Chapter 9.12, and the Health and Safety
Cee. Section 25532(.)?
HEATING UNIT (OVER 100,000 BTU)
TO
VENTILATION FAN (SINGLE RFSID)
13 Yes 11 No
Will W, co imuncefmure building me ups muse crm Ainmuality Management
hamrdous tir comaminends as define by the Bay Area Air Quality Management
District?
❑Yes 0 N
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health d Safety Cee, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant that it is my ramonsibility to notify the
mcupant of the ro,ircments which must be met prim to issuance of a Certificate of
Occupancy.
BOILER -GQMP(3HP OR IW,IXq BTU)
�SUpNCE DATE
^ 1)
MAR Z 1 nn
I a�
/JJ5
J^ L(3r-[H/11v
Y
ISSUED BY:
BOILER-COMP(OVER 100,000BTU)
NEW RESIDENTIAL MECH. SQ. Ff.
Owner or authorred agent Date
TOTAL:
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