27989 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO TNA "' PERMI'TNO.
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27989
BUILDING ADDRESS: SAND'ARY NO. APPLICATION SUBMITTAL
DRAM
2IG+ 1V UNIT# LOT# ��
OWNGit I CONPRACT N LIC NO: N/C CONIPLLL#
ARCIII'TF;CT(IiNGINTaiR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT B MITCH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
neiz lherebyaffinn Narlamlicenedunderpmvisionsof Chapmr9(commencingwith IPI ON
woo Scnion]IMgLd Divis on3mf the BusinnaanJ Professions Code,and my license is in PANELS=,C full fmceand effect.
1<.,Z to License Class Lic.p UPT02WAMPS
m<y D:nc Comonclor 201-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000AMP5 SQ.FT.FLOOR AREA $)SQ.IT.
OZ—m lundersmnd my plans shall be used as publi<mcord.
F^1=� SIGNS ELECTRICAL
<y j Licensed Professional
�aa'6 OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KC)aU 1 hereby affirm that I am exempt from the Contractor's License Law for the
a40 To following mason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
which requires a pmmm n consuuet..Iter,improve,demolish,or 0, any structure
o,To
poor its issuance,also requires the applicantfirfiPermit fleasiguedsmmme PO VICES
CpC p mm he is licensed pursuant to the provisions of the Camnnor's License Lew(Chep
ageW 9fnmmmencing wiiM1 Section]0110)of Division3afthe Business and Profess'a e) SWIMMING POOL ELE IC VALUATION
h703l. hy.uyrefromanA thebasisf..bj idle ppli—t.Any viola) not OUTLETS-SWITCHES-
FZQ Sation]U3 LS by any applicant(orapennit subjects the applicantmacivil rya( FIXTURES
ES rdP�fctsioa,
mum fvc hunded dollars(ES(q).W s oweroftheproperty,ormyemploymswithOagesasthei...let. avarice, NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPECONSTRUCI'ION
22 �work.andthe nmcrure is not in¢ndedorofferW(orotic(SaT Business
Cede.TM1e Cnnvunors license L.w Jres not apply m owner ofwhmbuildsm improves Narcan,and wbodmes such work himself nhmugh his
hoanployecs,pmviJeJ thauuch improvements am notimendedoroff dfmraae.If. / OCC.GROUP RISS.UNITS
wever,the building or improvement is sold within one yearofmmple on,thcowner-
builder will have the burden of proving that he did not build or impm for purpose of
sale.).
❑ I,asmwner.Rhe prnpeny.emexclusivelycumraaingwiNlicrn eJttmwdmrs[c QTY. PLUMBINGPR FEE FLOOD ZONE gpry
onsnuct the project(Sec.](W4,Business and Professions Cade:) a Contractor's
License Law doeanm apply m an owner afpropeny whobuilds or inner vesdhereon,and PERMIT IS E
who c.ntmcts f.rrvch projcaawith emntmc[crta)IiccnsW pursuanit0 Immora ALTER PA FEE SUMMARY
License Law. ( )
❑ 1 nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date
DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT'#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Wo ers Co pen Nmlhaveaeor ificmeofconsemromf(Scsurgor Lab C.)which FIXTURES-PER TRAP RECEIPT'#
Workers Compensation Insurance oraceniEW copy thereof(Sa.3800,1ab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(FA) PTANCHECK FEF,
LI Certified copy is hereby f caunhW.
❑ Cenifed copy is fled with the city inspection division. GREASUINDUSTRL WASTE INTERCEITTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This union need not be completed role permits formic hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY ME
or Ices.)
I certify that in the perf.mmance or the work fm which this permit is issued.)shall WNENTALECIR
not employ any person in any manner as to become subject m the Workers PAID
Compensation Lawsof California Date so t WATER SYSTF;M TING Date Receiptp
Q z Appliam
z NO'I'ICF:TOAPPLICANT:IL after making this Certificate of Exemption,you should EW RESIDENTIAL PLMEL SQ.FT. TOTAh:
rV) became"object'.d¢Workers Cma,masfion provision of the labor Code,you mus
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING TEF.
y Q CONSTRUCTION LENDING AGENCY ESFF
z I hereby affirm that there is a construction lending agency for the pert.rmmammce of 10
V O the work for which this permit is issued(See.3097,Civ.CJ ELenders NameULcialm's Address QTY. MECHANICAL PERMIT FEE EEI cenify that I have read this application and state Na the above information is
r�1 DQloacn.I.9.c[ccmmply wirh.11 city andcoumyoNinances andsmm laws edadngto PERMIT ISSUANCE MECej building conswetion.and hereby amM1mira representatives ofthis city[center upon the
V zabove-mvficned property for invpection purposes. ALTER OR ADD TO MECFL ON TAX
(We)agree m,ave,indemnify usd keep harmless the City of Ca,mr.aganst
4rce
dgmcrw,cossandrx,mxxwhiehhmy it yvmy a ccrue.gainsls.id City AIR HANDLING UNIT(TO PyNOCFM)
in conxe e. the granting of Nis pcnnit.
i AIR HANDLING UNIT(OVER HL"CFM)
<wUC'omncmr D e EXHAUST HOOD OMMUCTI
PAID
HAZARDOUS MA RIALS DISCLOSURE. HP,ATINGUNIT(TO 100,WI)BTU) Dme Receipt#
Will the applicant or hum,building Occupant same,or handle harardous materia HEATING UNII'(OVER 100,000 BTU) TOT
an Ached by rbc Cupertino Municipal Csdc,Cm,uc,9.12,wet rhe Realm and Safety
Code,Section V 532(a)T
❑Yes 11 No VENTILATION PAN(SINGLE RESID) L
\ BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
Ask, Will theappliam or future building Occupant use equipment or devices wh emit
haearduir comuminamx m defined by the Bay Ara Air Quality Mar ,mood BOILER-COMP(OVER 100.(100 BTU)
etri<t?tT B
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. PA
Loy's
red the haAnus mmeriaE requirements under Chapter fi.95 ofme ��� ��qqor
alth&Safety Cade,Sections 25505,25533 and 25534. 1 understandths 19g Jmcs nm cnrcn0y have a rcnan6 that it is my responsibility m notify thetelt-
he rquiremems which mus be met prior rt'issuance of.Certificate of Cq(� Ilmnaed agent Date TOTAL: ISSUED BY: 1
OFFICE