27745 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE SALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO. /I
APPLICATION/PERMIT PLUMBING-MECHANICAL `i
BUILDING DIVISION BUILDING PROJECT IDF.NTIFICA'I']ON
ILDING ADDRESS:� (�J SANITARY NO. APPLICA'OONSUBMITALDATE UN N LOT It
I HONE: C DR'S N E:_ Li0 NO:
r 15447 TT V NEC11
CONTROL M
C -Cf/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: -"C
QTY. to HCECTRIC PERMIT - FEE BUILDING PERMIT INFO
BL gG ECT PLU MECH
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL 1a
p8zo Ihertbymfirmision amlicensedinss and oilesof@epw9(commeneise with 'I IrfJJ
00❑ Sectionciind of Division3of the Business and Profession Code,and my license is in PANELS (� N!v-iXV.�
KUu full forceand effect.
FZW License Class Lic.X UP T0200AMPS yF-Qy Date ma
Conor 201-I"AMPS
ZOy2.� ARCHITECTS DECLARATIONOVER 1000 AMPS
SQ.VT.FLOOR AREA S/SQ.Er.
O Z—O 1 understand my plans shat)be used n public rtcmAs.
N
W SIGNS ELECTRICAL
Q"�d :1 Licensed Professional
MAd OWNER-BUILDER DECLARATION SPECIAL CIXCUIT/MISC, r�
P�Oa I hereby effort that I am exempt from the Committers License Taw for the
W 3 0.y following reason.(Section 7031.5,Business and Profession Cade:Any city mcounty TEMP.METER OR POLE M
O
1iJ er
which e,mms a pmit to sw
car ct,dter,improve,demolish,en repair any amettim
yY� Prior to its issuance,also naves the applicant farwch permitto file s signed statement FEWER DEVICES
a�<O that he is licensed pursuant name provisions of the Contrecaae.License Law(Chapter
�k00! 9(commencing with Section 7")of Division 3 of the Business and Professions Cade) SWIM OL ELECTRIC VALUATION
W'^y or that he is exempttherefrom and the basisfor the alleged exemption.Any violation of
LZY Section 7031.5 by any applicant fora permit subjects the ap,li.t so a civil pertZ of S-SWITCHES-Fl%'TURES
7C 0 not more than five hundred dollars(SIM). NEW RESIDENTIAL ELEC R 5 .Ff.
W it ❑ othow k,o d, sMetu isnoti pmdy oroffe g ors eiraoleco ,Bus teas —SQ.FT. TYPE CONSTRUCTION
-_ will dothscdmk ande noCureisnm is License La c does
1.cal vHe,of
and Profess ns Code:The Convector's License Lew rices not apply to un owner of r
ownevywyess,powidedprovsthemprove whodoeswctended roffeorthroughhis OCC.GROUP RFS.UNIT'S
howemployas,p Ing ori improvement
at himpis sold within
not intendeampleeon,Me
If,
howcva,the building orimpmvcmcm is sold within one yearafcompletion,the owner-
builder will have Elie burden of proving that he did not build m impmve for purpose of
wnero0he pmpery.emexcludvelycontutingwithliccnsed Cantractoratm QTY, PLUMBING PERMIT FEE ROOD ZONE APN
me. Ne project(Sec.7W.Business and Professions Code:)The Contractors P IT ANCE
ivirtu Law does not apply W an owner ofproperly who builds or bnproves themen,and
who comment for such projects withacontmetor(s)licened pursuant to the Connector's LTER-DRAT VBNT-WATER(EA) FEE SUMMARY
License Law.
❑ laexempt under See. ,B&P C for thiswon BACK ROW PROTE VICE OUTSIDESANITARY Y N
Owner RAT DRAINS-ROOR,ROOP,A . OND. RECEIPTX
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IheCondemvmin Insurance
or lfcateedcopennreaf(ec.31.0,aaC.)wmof FIXTURES-PER TRAP RECGIPPX
Workvi Condemnation lnaunnce nrecenifiW copy thereof(Sec.3g00,Lab C.7 which PARK PEE YN
Biffil—
overs till employees under this permit. GAS-EA.SY -I INC. EPS � RDGIS101
/ PolicyM /� BUILDING DI VISI
CmnMnY GAS-EA.SYST VBR 7 PLANCIfF.CK FEE
❑ Certified cmpy is hereby famished.
❑ Certifiedcopy is fled with the city inspection division. GREASr0kUjW.WAS 1NTERCHPJJy GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASET P SOILS FEE.
COMPENSATION INSURANCE
This section need not becompl,tedifthepcmit is forma,hundred dollars I$. ) SEWER- TARY- ORM F.A.2WF1.I ENERGY FEF.
or less.)
I certify thin in the Performance office wort for which this permit is issued,Ishall WA TER /ELECfR
oat employ any person Orany manna sec as to become subject to the Workers PAID
Caepensation laws of Ca ifomis. Dau W EATING Dau 'eipt X
O z Applicant
�Zyy 0 NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you should NEWR DFNTIAL PLMB. TOTAL:
rlp bermic,ubject to the Workers Campenetion provision of be Labor Code,you tont
tom . forthwith comply with such provisions in this permit shill be deemed revoked. BUILDING �•
Q CONSTRUCTION LENDING AGENCY SEISMIC
z 1 hereby affirm that there is a construction lending agency for the performance of L EL[ FEE
U O Ne work far which Nis pemut is issued(Sec.301 Civ.C.)
Ir Leider¢Name
U^ P lenders Address QT.Y. ,- MECHANICAL PERMIT FEE PLUM1IfGjE
0 LUk1 I certify that 1 have read this application and scene than the above informed.is MF.CHANICAI.FF.E
rom I ague m Comply with iry eM county oNinenca end sure lewa Helium,m PERMIT ISSUANCE /ate
cuiLrr
lding consmcuon.end hcrtb a rise rtprtunuuvesof duacity ro emetupon Ne CONSTRUCfI TA%
U ,z mentioned propeM forms
or in tionpurposes. ALTERORADDTOMECH.
v�WeI agree to nave,indemnif d keep harmine the City of Cup,ninn against
limb it ,judgmenthastseadexpen swM1icM1 may in any way accrue�einst 'd Ciy AIR HANDLING UNITfTO IU,ODO CFM)
f resting of shi I
AIR HANDLING UNIT(OVER 10,1101)CFM)
Signw Applicant/Ca ONE EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0011 BTU) Date On
Will the applicant or future building occupant store m handle hazardom material
n defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOR"BTU)
Code,Section 25532(x71 VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 100.000 BTU) 1 SU CP YDIATE
Will Hair eco amtmms ea defined
by the
nBay Amu
Quality Management
All
{' y
hawdous air contamittenb o defined by the Bey Area Air Quality Manag,mrnt BOILER-COMP(OVER I)T,1K10 BTU)
IstriCO
❑Yes ❑No NEW RESIDEMMAL MECH. SQ.FT. CSI y 49
1 have read the hazardous materials mquimnents under Chapter 6.95 of the _7feTY
Culifnmia Ifeelth&Safety Code,Sections 25505,25533 and 25534.T understand the, C
if the building does not currently have a tman,,that it is or,responsibility ro notify the J
occupant of the requirements which must be met prim to issuance of a Certificate of
Occupancy.
Owner or arized agent Date A ISSUED BY:
who -
OFFICE