27351 _w1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPENO APPLICATION/PERMIT PLUMBING.MECHANICAL PERMIT NO. 27351
/ BUILDING DIVISION
N BUILDING PROJECT IDENTIFICATION
BUu.DINa ADD RE Q 1f�, SANITARY NO. ^A7PPLICATION SUBMITTAL DATE
l0� B V• UNITIt LOT#
OWNERS AME: PHONE:O gC1'OR'S NAMG: {.IC ND: O N/C ��CCONNTHO•LL##1��iI
G S V f Y
IRC ITB A' GINF.> C O: ADD ESS:
11�/' O G L W G>
'ONTACfi PHONE: .:'ELECTRIC PERMIT. FEE BUILDING PERMIT INFO
Irj �5
ELECT
PERMIT ISSUANCE BIDG P UMB MCH
LICENSED CONTRACTOR'S DECLARATION pppLNNCES-RESIDPNfIAI. TOB DFSCftIPHON
OyZ Ihemby affirmthat l mo Rcensed under providonsof Chapter9(commencing with
00 Scelian] fDivision Jof the Boniness and Professions Code,and my license is in ppryBLg
rce a `
y full fonmald aRecl. Q
G � Licrnee Class Li..It UP 702110 AMPS
y Dom Comtrns, 201-1000 AMPS
ZFO
on K. ARCHITECTS DECLARATION OVER 1000 AMPS SQ.PT.FLOORAREA5/S .FT.
Z po 1 undessCamJ my plana shall be used as public records. �A/( —f-f`
W SIGNS ELECTRICAL [/..Ag i'�'
Licensed Professional J
�ya'6 OWNER-BUILDER DECLARATION ECIALCIRCUIT/MISC. Oct
kOaU I hereby affirm that 1 em exempt from the Contracmis License Law for me
213 LLIn following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METRIC OR POLE INST.
-�
to which requires a pe.I'm emuarun,after,improve,demolish.or repair any,structure I
cpcp°'} prinrto its iasusmce.also requires lhevpplicant forsuch permit to fileaeignedsatement POWER DEVICES
y�pp that he is licinsWpursamil to the provisimix ofshe Conracm's Liceas Law(Chapter —�
o.XXao 9(commencingwith S,etion 7000)of Division 3oOhe Businessand Professions Code) SWIMMING POOL ELECTRIC ALU TION
Iy..m onM1at he is exempt mercfrom end the basis for me alleged exemption.Any violation of �-
�ZQ Senior 7031.5 by any applicant for a permit subjeas the applicant to a civil penahy of UTI-EfS-SWRCHES-FIXTURES
not mom than live hundood dollars($5110). NEW RESIDENTIAL ELECfR 5 .
❑ I.asownerofmhepropeny,ormyemployceswiahwageaas[heirsolecompenmu.on. QPI'.
STORIES TYPECONSTRUCDON
y will dodo,work,and Cheaaunureisnof intendedoroffgred forsnla(Sea.70C4,Business
and Professions Code:The Cont,.,.es License Law does not apply to an owner of
propenywM1obuildaorimprovrs
the reon.and whadoessuch work himselfordmi,i his
owmemployces.providedahnt such improvements amomimendWorofferedforsale.If, OCC.GROUP RES.UNITS
however,the buildingorimprovemem issold whinnone yeu of completion,theowner-
builder will have he/it,.
ving shit d not build or improve for purpose of
ole,).
❑ I,ssowncrofme uaivclyvmC ng with licensed contemns to QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
soma me projeComets end Proles
no Code
The Contractors PERMIT ISSUANCE
License lawdoes not applywn,rofpropeny whobu sorimprovwmcrcon,and
whocommcCsforsuthacomracmr(sHicemed mullomeConvectorsTF.R-DRAIN&VENT-WATERLicense Law. (' D r FEE SUMMARY
❑ 1amexemptu ,B P C for this reason ,FLOW PROTECT.DEVICE OUTSIDEMES,
SANITARY YN
Owner Dote RECEIPT#
WORKMAN COMPENSATION DECLARATIOt DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTAX YN
47!",
1 eby affirm thsClbaveacenificamofcomentmself-insure, acenificaterf RECEIPTp
FlXTURES-PER TRAP
nComprnamlonln111, oraceni0ed copy Cher,of(Sac,38W, .ab C.)which �� PARK FEE Y N
c ars ellemployeea under tis permit. GAS-EA.SYSTEM-I INC.40UTLETS RECISION
P IicyM BUILDING IVISION &LfJ
C mpany GAS-IA.SYSTE ER4(EA) PLANCNECK FEE
Certified copy is hereby furnish
Cenifiede,yisfiled immecit ivision. GREASE/1 STRLW ;TE INTERCEPTOR GRADING FEE
CERTIM O ON FROM WO IS GR TRAP SOILS FEE
v.. ON INSURAN
(This aionne,dnotbe o letadifine penniliaf onelounraddollers(fIW ,EWER-SANITARY-S RM EA.200FT. ENERGY FEE
m itaxJ
IcerofyUl 'nth,perform ofthe work for ich mivpermit is issued lshall WATER H TERWNE RLECTR
not employ any on in,any rnaaat an as become subject,to the W rkcm' PAID
Compensation laws !C#lifomie. Dem WA RS /ITC NG Data Rec aq
OV)Z Applicant TO O�.2Q
NOTICE TO AP.tho :ILafter maki @is Cenifnte of Exemption,you Dula W B. SQ.FT.
^� becom<subjauo m,W cts Compen tion provisinv of the LaborCWe,you n
> forthwith comply with ser provision Ibis permit shall bedeemed revoked. BUILDING E '�
I
0. (� CONS ON LENDING AGENCY SEISMIC
U z I hereby affirm mat there is v construction lending agency for Che perfatman
Ne work for which this permit is issued(Sec.3097,Civ.C.)U. ELECTRIC FEF.
1<nders N
Q ertm
0 U I andeis Address FE
QTY. ECHANICAL PERMIT FEE PLUMBING E
U I cm:nify that 1 have mad Nis applicaminn and state that We above information a
1 cones.legree menmply with all city and coumy oNinermu end cram lawn relating P ITISSUANCE MECIIANICAL FEE �.
I-' y buildingcovouction,and hereby numoriu reprcscmadvesrfmis city in enter upon th CONSTRUCTION TAX
O Z above-mentioned property for inspection pasposuv. ALTERORADDTOMECH.
(We)agree to aave,indemnify and keep harmless the City of Cupertino against
lialaditm;,judgmeaa,costs andesMnses which may in any wayacnueagainst mid City AIR HANDLING UNIT(TO 10,000 CFM7
incomsequ of the grvmingadlis psmdt.
AIR HANDLING UNIT(OVER 10,00N0 CFM)
Ili, Signature of Applicen4Cwvunnr Dae EXHAUSTHOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BT ) Dam Receipt#
Will the applicant or faurc building Occup.,state or handle haeardous material
u defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety HEATING UNIT(OVER 100.000 BITH TOTAL:
Cody.Section 25512(o)i
❑Y. ❑No VENTILATION FAN(SINGLE RPSID)
BOILER-COMP(3HP OR IM."BTU) ISSUANCE.DATE
WillthevpplicwCarfmurebuildingoccupenmseequipmemordeviceswhichemi[ A
azardous air conmminanes as defined by me Bay Area Air Quality Management BOILER-COMP(OVER IOO,W)BTU)
i�
Dixuin7
D
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.IT. �PR 8 (15
`Chave mad the hradous materials requirements under Chapter 6.95 of the ryY 19
California Health&Safety Code.Sections 25505,M533 and 25534. 1 undersand mat V c q7J
.ifine building does not currently have a Camara,shat it is my responsibility to notify the U/' `UNL��/
I mcupam of the requirements which must be met prior to issuance ofit Certificate of
Occupancy.
Own u m nwho L,ed agent Dam T ISSUED BY:
OFFICE