27483 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOS<'-Et,bullit PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL p p
BUILDING DIVISION BUILDING PROJECTIDENI'IPICATION 7 4 O 2
BUILDING ADDRESS: SANITARY NO. APPLICATIONN SSUBMMIITTArL�DA
M LOT p I �2' 9�
NEMS AM^ oPHONE: CO OR'S NAM° LICflO:� N/C L CONI ROi,q
AR 11 ECT/ENGINE[R: LIC NO: ADDRF `��C.YYJ)'
corrrncr: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT tLuslIddB MECH
S PERMIT ISSUANCE ❑ ❑ `Kfl El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTIONMai I hereby uffirtn that 1 am IicenecJ underprnvisinnsofCTapmr9(commencing with
�00 Section 70W)of Division 3 of the Business and Professions Code,and my license is in PANELS
ys V F fall force and eft
FQ-Zw License Chis Lic.p UP TO 200 AMPS L
mQy
Data Cont 201-I"AMPS
%Ov,r' 1 and A shell TE D ,ARATION OVER 100)AMPS
SQ.II'.FLOOR AREA $/SQ.FL
SIGNS ELECHUCAL
Lhce J
Mcwu w NER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X06 V mreI aft that I am exa opt tomo the Contractors License Lew farina
Fop to wing ra Scdion7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
Which requnes a permit ro conswet,¢Iter,improve,demolish,or repair any meacmhrt
Nprior m its iwuance.also reanmit
quires thait"Ict for Such pcom Bea Signed numerator POWER DEVICES
ty Y Q 0 that he is licensed pursuant re the provisions of the Contractors License Use(Chapter
a Xo�, 9(commencing with Section 70)0)uf Division 3 afthe Business and Professions Code) SWIMMING POOL EIECIRIC VALUATION
I, , or IMI he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES FIXTURES
F Z Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of
5a<p nut moa than five hundred doll.,(S500). NEW RESIDENTIAL ELECIR _SQ.FT.
n'!'o ❑ hasowneroftheproperty,ormycmployecswithwagesazthcirsolecompeaaton, STORIES TYPF;CONSTRUCfIOD
y322 will do the work,and the sttucureis not intended oroffered forsak(Sec.70#4,Business
and Professions C:uc:'ITe Contractor's License Law does not apply m an owner of
property who builds or improves the:con.end who Jens such work Nimselforthrough his
employecs,provideJ thauuchimprovememsare nooimendedoroffcad forsale.If, OCC.GROUP EU'Nl�however,the building or improvement is Sold within one yearofcompletion,Heowner- TOTAL:builder will have the burden ofproving that he did not build or improve for puopns ofsale.).
[ILusownerofthe propmy,am exclusively contracting with licensed contractors m QTY. PLUMBING PERMIT FEE FLOOD ZONE
exanstract the project(Sec.7044,Rosiness and Professines CWc:)The Contractors
License law does nmapp]yto anowncrofpoopeny,who buildsar improves thacon,and PERMIT ISSUANCE
whocontmctsfor such projects with acnnhactorts)licensed pursuant to Ne Contractors ALTER-DNAIN&VENT�WATER LA
License Law. (' ) FEE SUMMARY
❑ Lam exempt under Sec. ,B ffi P C for this rtason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y_N
Owner Date DRAINS FLOOR,ROOF, RECEIPT#
-
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I heodyafinm that l have acenificam o(consent.self-insum,ora cerifiwm of RIiCF.IPT#
FIXTURES-PER TRAP
Workers11 anrppen.wti otosutunee<racmifiedcnpy thereof(Sw.3tl00,Lab C.)which PARK FEE Y N
Policy covers pllemploys�yuyf)<yr rhi/mylry(� /'l-+ GAS-EA.SYSTEM-I INC.40I1TLE1'S - ��:4 BUILUINGI CEIPONFRFS
Company , �iT`�—S\['(Q�j/,)
GAS-EA.SYSTEM-OVER 4 IEA)
...❑JJJ Ca.Hadoop e f LANCHECK ME
vg Cert ilied ropy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPI'O GRADING FEE
I �• CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forum hundred dollars($100) SEWER-SANITARY-STORMEA.2 114 ENERGY HE
roles,.)
I certify that in the performance ofthe work for which this permit is issued,i shall t WATER HEATER W/VENT/LLECV
not employ any Person in any manner SO as to become subject to the WorkersPAID
z Compenwtionlawaof Ctlifomie. Date WATER SYSfEM/IRFATING Date Beccipa#
Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RES, IS
FT. TOTAL:
f" rte. become subject to the Worker's Compensation provisions ofthe Labor Code,you must
> foMwith comply with such provisions or this permit shall be accused awaked. BUILDING HE
ILCONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm that then is a construction lending agency for the performance of
U 0 the work for which this permit is issued(Ser.3097,Civ.C.) TOTAL: O � F,CfRICFEE
Leader Name
OU lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING HE _+
I certify that 1 have read this appliciamor and state that the above information is
Fcorrect. I agree to comply with all city and county ordinances and state laws relaingtu PERMIT ISSUANCE MECHANICAL HE
� building construction,and hereby authorize representatives ofthis city m enter upon the
V Z aMve-mentioned prnpeny f oyJec�nn qt s ALTER OR ADD TO MEGH. CONSTRUCTION TAX
(We)agree a a m cfinify�^�Jkm¢y'��fnnless the City of Cupertino against
Iiabilities,jud ¢#Enos <G h may in any way aceaeagarsO Said City AIR HANDLING UNIT(TO 10.000 CFM)
in cunscque fib unit.
AIR HANDLING UNIT(OVER 10,000 CFMI
nano omrector am EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSE fIEATING UNIT(TO IW,ODO BTU) Data Ncceipt p
Wi c applicant or future building Occupant done or handle Imeardoes material
as defined by the Criterion Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER Dart,"BTU) TOTAL:
Cade.Section 25532(x)1
❑Yes 0 N VENTILATION PAN(SING CC RESID) —
OE�T8
uWilhheaPPlicamorfuwrehuilding occupant usceyuipmentor Jcvlces which unit BOILER-COMP QHP OR 1 ISSU
01,000 BTU) IA'N!1 L/
•hardous air contaminants as defined
-COMP(OVER L W,0o0 BTU)neJ by the Ray Arco Air Quality Management `
DiatrieTl JAN 27 (�e
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.tT. TOJJ
I have read the hazardous materials requirements under Chapter 6.95 of the CITY JJJ
if be trading
SafetyenJy haveiunsem.that
it is ybeigi34. tun 1.amid that Ur LUNttl I1ry�
if the building does ria currently have a Rnant,Ohm it is my aaponxibility to notify the
occupant of the rrymberna u which must be met Prim to issuance of a Certificate of
Occupancy.
Owner or amhonuJ agent Date TOTAL: ISSUEDBY:
OFFICE