27557 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING�AD/DRESS'S' A /�y�.n �j��� SANITARY NO. APPLICATION SUBMITITTAL DATE
ZL A445 4pRbYZ 1 INO I�1'1 UNIT# MjIl.r> Csa LOTH
O PRS NAME: PHONE: CONTRACTOR'S NAME: '.A LIC'NO:
su. MELPWMW�t-I'aA..a N/C CONTROL Is
CIII'IECT/ENGINEER: NO: RESS: ❑
►SID oGIP. LIC IS9'0 'TAW W RWC.
CONTACT: PHONE: - ,t BUILDING PERMIT INFO
e
QTY. ,h ELECTRIC PERMIT FEE
2AN BLDG PLUMB
PERMIT ISSUANCE
eya—�1 `Ly�•
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL C
py�Z Ihereby affirm that l am licensed under provitionsof0hapter9(commencingwido
POLI Section 700E.f Division 3 ofthe Business and Professions Cade,and my license is in PANELS • '—
FIY U full fome and effect J
Qz W Licenu Class Lic.p UPTO200AMPS
y 6 e, Dale Contractor 201-1000 AMPS
FyZ ARCHITECTS DECLARATION SQ.IT.FLOOR AREA S/SQ,PT.
ZZ-0
O sh
I understand my plans all be used as public records. OVER 1000 AMPS
W SIGNS ELECTRICAL
Q� -.�I Licensed Professional
gK Q OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°x'OaUFFF I hereby affirm that 1 nn exempt from the Commcmra License law for the
Ia)3It. followingrcasom(Secdon7031.5,Business and Profeasiorn Cade:Any cirymcaunq TEMP.METER OR POLE MST.
fc kJ NO which requires a permit m construct,stmt,improve,demolish,m repair any structure
1d� ;; prior to its issuance,also reyuirealhe applicant for such permit to rile aligned mombam Po DEVI
_<O that he is licensed pursunat to the provisions of the Contractors License Law(Chapter
n6x eC 9(commencing with Section 70110)af Division 3 ofthe Business and Prafessions Cod S I LELECTRIC VALUATION
�)
:02 at ar that he is exempt therefrom and the basis for the alleged exempfio nyviolmiono -SWRCHES-FI%TURPS
� < Sermon 70)13 by any applicant forepermiuubjectsthe epplicnno ivil pe of ,
$ t mare than five hundred dollars(ESBo). NEW RESIDENTIAL ELECIit _SQ.FT.
c' p n❑ Lasownemfsheproperty,ormyemployeeewithwages esth ' n, STORMS TYPE CONSTRUCTION
y3. will Jothe work,endthestmmum isnot intended orof(ered fmsele(Scc. ,B sinal
and Professions Code:The Contractor's License Law does not apply m m of
pmpenywhobuildsorimpmveuhee n,andwhodoessuchworkhimulfm ughhis
employees,providedthat suchimprovementame not imendedaro!fend fmsale.11 OCC GROUP RFS.UNITS
however,the buddingmlmprovement ismid within one yearafcourpletion,theowner-
builderwillhavethehumanof that he did not build m improve purpose of
TOTAL:
proving prov purpo
ale.).
❑ hmownendtheproperry,amexdusivelycontruting with licenud convactanm QTY'. - PLUMBING IT FEE FLOOD ZONE APN
comm of the project(Sec.7044,Business and Professions Code:)The Comruters PERMIT ISSU
G cense law docs not apply m n owner of property who bui lds or i m prove thereon,end
whocontmetsforsuchprojectswlthacont=mr(s)licnaedpursunuothe Conumr's TIER-DRAIN&VPNf-WATER( ) FEE SUMMARY
License Law.
❑ I am exempt under Sec. B&P C for this rt BACK FLOW PROTECT. T ID
EVERi
SANITARY Y N
DEVICE
Owner Dete RECEIPTM
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROORIA,GOND. SCHOOL TAX Y_N
❑ I hereby sublimation l have acertifieateofeansent to ulLinnrt.ora rtificate ofRECEIPTp
WmLv Compensarin Tnsummoramnificdcapythereof(Sec.3800, N
C.)which Rx HES PARK FEE Y N
coven Wl employee'a under this Permit. GAS-PAS S INC.40 RE FIPT#
.
Policyp DING VISIONFEES
Company GAS- TEM-OV 4(14) PLANCHEC
[2mi
CenifiedcopyisherebyfushW. g
❑ Certified copy is Clod with the city inspection division. 0. SFIINDU W INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' R TRAP S
COMPENSATION INSURANCE
(This action need not be completed ifthe permit is for am...dollers( ) SE R-SANITARY-STORM FA.3(lU GY FEE
or less.)
I certify that in the perfarmarxe ofthe work for which this permit is issued,l shall WATER HEATER W7VENT/ELECfR
not employ any person in any manner sec as to become subject to the Workers' PAID
Compnsmamlawsof Cn ifomis. DateWATERSYSTEMAREATMG Date ReceiptA
Q Z Applicant
z 0 NOTICHTO APPLICANT:IL after making this Certificate of Emorperm,you should NE PSIDENTIALPL SQ.FT. TOTAL:
bechwithc comply
the mchPr Compmaminp right
be d Labor Codayou must �` BUIL ING PEE
forthwith comply wit�such provisions m this pemtit shell be deemeA revoked. �.a
(] CONSTRUCTION LENDING AGENCY SEI IC FEB
a Z Iberebyaffirm Nat there iso cunaucfion lendingagency for flepMomanceof EL GUCFEE
V O the work for which this permit is issued(Sec.3097.Civ.C.)
O
Lender's Nome r PL BINGFEE
Lendets Address QTY, MECHANICAL PERMIT FEE l�
I certify that 1 have read this application and state that the above information is MECH LCAL FEE
7" cancer.I agree to comply with all city mel county mdiammes and nate laws mlating to PERMIT ISSUANCE
V z buildirt,em r mionNa
,and herebyaurirertprtscntatives ofthiscity,I. upon the CONSTRU ONTAX
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino Melon
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO I0.0nd CPM)
in cause ce of the . of Nis permiv _
AIR HANDLING UNIT(OVER 10.000 CPM)
t
gnaw of Applicnt/ omNeor Data EXHAUST HOOD(%DUCU
PAID
HAZARDOUS h1ATERIALS DISCLOSURE HEATING UNIT(TO 100,003 WITH Date Re eip N
IV
ar-
Will the npplicam err funrc building mcupam stem orhndle hezardom memriel r.1 EATING UNIT(OVF.R 100,000 BTU) OT
n defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 75533(.)1
El Yes ❑No VENTILATION PAN(SINGLE RPSID)
ISS ISE DATE
Willtheapplicammfutum buildingmeupnt useequipmentordevlceswhicheath BOILER-COME QHP OR 100,000 BTO) q I D
her us air conmminsnm a defined by the Bay Area Air Quality Management BOILER-COME(OVER IN,"BTU)
DisRicR JgII/ aj
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT. v. V
I have mad the hvaNws materiels requirements under Chapter understand
of the Cll�'l,-
ifteCalifornia building
do s Safety Code,Sechave
ate 25505,25333 t itisy responsibility 1 understand that a/!' (c(/
ifthebuildingdoesnommem, yhaveatenantetitis my o . a ificat the
cupam of the rcyuircmems which most be met prior to issuance of a Cmificate of
Occupncy.
Owner or authodred agent Dam TOTAL: ISSUED BY: