27345 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITXOF CUPERTINO � PERMITNO.
f»,r APPLICATION/PERMIT PLUMBING-MECIfANICAh 27345
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BUIL r .DIVISION BUILDING PROJECTIDENTIFICATION LIJ
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BUILDINOAUDR[SS: ,..�`�{�y�� SANITARY NO. AWL CATION SU
B
MITTAL DATE
�• �r'iV\` ` — � UNITM LOT# 1 `.
I O0. "R 1" w IQ IOyI; COMA ME: LICNO: LV/�,
!/r l_kll y N/C CONTROL k
ARCIIHFC'DEN EER: LIC NO: ADDR S : ❑
'ONTAcr: PHONE: QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT P UMB MECH
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LICENSED CONTRACTPERMIT ISSUANCE E OR'SDECLARATION APPLIANCES-RESIDENTIAL L� JOB DESCRIPTION
Wpa'Z Ih7W)ofirtnthml am 31dth Btesitsed under proPrefelamrsCde,and
he.g with
F-00 Section a and of Division 3 of the Business end Professions Code,and my licrna is in ppNFj-g
ly- {' full forceandeffect.
�Ly) License Clans Lib- UP T02W AMPS
6 y Dam Comorator 201-1000 AMPS
ZO,z ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.n.
O Z—O 1 understand my plans shell h used Ns.
as public reco
1=:n H; SIGNS ELF,CIRICAL
%.a Licensed Professional
4p�U OWNER-BUILDER DECLARATION SPECIAL CIRCU gyL1�C.
X 4 F, 1 hereby affirm that 1 am exempt from the Contractors License Law for the n ° p
1sT a Orn following reason.(Section 7031.5,Business and Professions Code:Any city mcounty TEMPPMETERdiiikLEiNS
T. 11 I
which requires a permit to construct,alter,improve,demolish,or repair say structure
Y prim m its issuance.also requires the applicant for such pe.iuo filed,rod uIDCmen, POWER DEVIC (�
z S I^ 1
ty K O p that he is IicenuJ pmauam to the provisions of the Cono-nor's License Law(Chapter — - . u
ap�(,o�' 9(nnnnsncing with Scctinn 7lNl(1)of Division3oflM1e Business and Professions Code) SWIMMMG POOL ELECTRIC VALUATION
Wim orth:n he is,xempuM1crc(mmanJ the basis forthc alleged exemption.Any violation of
FZa Section 7031.5 by any applicant for a permit subjects the applicant a civil Penalty of OUTLETS)-SWITG A�
AZO not mrrelhan five hundred dollars($5Wy
gets ❑ I,usownerofthe n orm NEW RESIDENTIAL ELECTR S .PT.
#rope y, yemployaswiNw gesaslheirsolecompensauon, Q STORIES TYPE CONSTRUCTION
('322 will do the work,and the.swaare isnorimcndcd oroffcred for sale(Sec.71kO,Business
and Professions Code: Do Contractor's License Law does not apply to an owner of
property who builds or improves Nercon,and who does such work himselfor through his
cmployas,providedthmsuch improversmmare not imendederoffbred(orale.If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofeompleuon,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,usownerortheproperty,umexclusivelycontracting with licensedemracmrsm QTY, PLUMBING PERMIT FEE PLO ZOZONE APN
onstract the project(Sec.7U ,Business and Professions Code:)The Contractor's
License Law does not apply manownerofpropeny wholailds or improves thereon,and PERMIT ISSUANCE
whocantacts fors.h projects with acanuactor(s)licensed pursuvtt to the Contnetors ALTER Law. WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN_
Owner Data __DRAINS- RECEIPT-
WORKMANCOMPEN3ATIONDECLARATION FLOOR.ROOF, COND. SCHOOL TAX Y N_
❑ rhereby Carep, -tion Ilhaveacenihamcofmmy ffiemlGinsum,macenificme of FIXTURES PER TRAP RECEIPT#
Worken'Compenationlnsuranccoracenifiedcopy thercof(Sx.38W,Lab C.)wbich PARK HE Y_N
crwcn all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy k
Company BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER FA)
11Certified copy is hcmby famished. ( PLANCHECK FEE
❑ Cenifted wpy is filed with the city inspection division. ORW- EANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Bible permit is Lorone hundred dollars($IW) SEWER-SANITARY-STORMEA.2WFT. ENERGY MEor Ica.)
I cannily that in the performance ofthe work for which this permit is issued.l shall WATER HEATER W/VENT/ELECIR
nm employ any person in any—1 so.to become subjxt to the Workers'
z PAID
Applicant
Comperailmo Lawsof California. Date WATER SYSTEMITREATING Date Receipt#
Q
z 0 NOTICE TO APPLICANT:IL after making this Ceni raffle of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT. TOTAL:
r Cl) su
become subject to the pmla
Worker's Cotntion provisions of the Labor Cad,.you must
> forthwith comply with such Provisions or this p,m shall be learned revoked. BUILDING FEE
ped, ❑ CONS9'RUCTION LENDING AGENCY SEISMIC PEE
z 1 hereby affrro that there is a commotion lending agency for the peRormanae or
(� O the work far which this permit is issued(Sec.3097,Co.C.) ELECTRIC FEE
Lenders Name
00 U Lemler's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have teed this application end state that the above information is
1 correct. l agree to comply with ell city and county ordinances and state laws relatingto PERMIT ISSUANCE MECHANICAL FEE
building coov,uction,and hereby authoma reprcsenti ives of this city to enter upon the
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCIONTAX
(we)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitia,judgmenls,costs andexpri which may inanyway accrue natural said City AIR HANDLING UNIT(TO IBM CFM)
in conse,ucnce of the granting of this permit.
AIR HANDLING UNIT(OVER IfkIXq CFM)
Sigrmwrc of ApplicanVCommcmr Dale EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(B)IW,WO BTU) Date Receipt#
Will the applicant or future building occupant sore or handle historical material
as defined by the Cupanino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1 W,OS)BTU) TOTAL:
Code,Section 25532(.)1
11 Yea EI No VENTILATION FAN(SING LE RPSID)
Will fhee licant or fuutrebulldinmcuaal use BOILER-COMPTHPOR IW,00OBTU) ISSUANCE DATE
PP g p cqt Air Quality
Martichemil
i mw air.ntaminmts as defined by mh,Bay Aree Air Quality Management BOILER-COMP n �p I D
91(
OiaricR (OVER IOU,(1W BTU) f M
El yes CI No NEW RESIDENTIAL MECH. SQ.IT.
I have read the hazardous materials 5505,25533 under Chapter 6.95 of the 8 1
California H99
enri &Safery Cone,Sections25505,25533 25533 and 25536. 1 undersNnd that NOVII
if the building does not lament,have a tenant.Ilial itis my rcarymsibility w.miry the
acupvm of tee 1 Qahemcros which ml h m pi m Ivsu+nrn ora Ccnificma of
Occupancy. CITY Uf Wr
Owns uthoriud agant xzewk
am TOTAL: ISSUED BY: J
OFFICE