27727 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO .. CKC'I RICA] PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. f�
BUILDING DIVISION BUILDING PROJECT IDENTIF'ICA-1']ON G
MELDING
ADDRESS: / C ( /1../-�` SANITARY NO. APPLICNTONSUBMHTALDVC
V / ,c-7G ✓TY/C� UNITk LOT p / Z Z � 9
OWNFRS NAME: PHONE: CONTRACTON'S NAME: LIC NO:
f/ N/C CONTROL
It\NCIII'i liC'i/tiNGIN[Ili: LIC NO: AD11 DRESS: 6 ❑
'ONTACI': PHONE: BUILDING PERMIT INFO
Ido/e or
K/C h 3�r-16
/6( 0 QTY. ELECTRIC PERMIT FEE
W BLDGELECT PLUMB MECH
PERMIT ISSUANCE mi 1:111 El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL �F�'
Oo'Z Ihereby affim rthat l am licensed underprovisionsofaapter9(commencingwiN LOB DESCRIPTIONrs
WOO Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS C/1/JYId/C�- /—ey/jyfl
C V full force and eff� �I �J-
1<zW License Class ` 29 Lw,# ` 3n UP TO 200 AMPS
vt,Q=y Date y_Contra
nor /{l. 201-UXIOAMPS
ZOssooZ AIIICHITF.CTS DEC RAY ION C/ OVER IOOO AMPg SQ.FT.FLOOR AREA g/SQ.ET.
O Z—M I understand my plans shall h used m public records.
W SIGNS ELECTRICAL
Licensed Professinrul
CCQ OWNER-BUILDER DECLARATION SPECIAL CIRCUHDMISC.
KO W, I hereby affirm that I nn exempt from the Contractor's Licertu law for the
1+13 a y following reason(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
F-u-O j which requires a permit to concoct,spar,improve,demolish,or repair any sweturc
'WW ;? prior to its issuance,also requires the applicant for such Permit file a signed statement FEWER DEVICES
WW�O that he is licensed pursuanua the provisions of the Contractors License Law(Chapter SWIMMING POO IPCTRIC
'raF 9(connnencing with Section 9000 of Division 3 of the Business and Prnkssions Code) LU
m_rn or ilial he is exempttherefrom and the basis for the alleged exemption.Any violation of ATION
o
FZQ, Section 7031.5 by any applicant for a permit subjects the applicant nu a civil penalty of OUTLETS-SWITCtHESt VA-FlXTURES,, TI� III Q o• C
ESO not more than five hundred dollars(55(10. v r p
wFm ❑ I,asownerofwe n,orm em Io eeswithwa esmthcirsolecom minion, NEW RESIDENTI L ELEGTR _SQ,FT. ,,
Props Y Y P Y 8 a " t� r STORIES 'TYPE CONSTRUCfIOp
63— willdo the work,andthe structure is not immadedoroffered formle(Sm.]D14,Business — — . v
and Professions Code:The Contractor.License Law does not apply m an owner of I a `n
property whobuikhorimpmves domeam,end whorl.such workhimselforNroughhis 1aIE
ownemploms,pmvidcdlhatsuchimpmvementsamnotintend oroffer fors e.If, DATE GROUP RES.UNITS
however,the buildingor improvement is sold withinone yearofcompletion,them ner- TOTAL
builder will have the burden of proving that he did not build or improve for purpose of `J.
sale.).
❑ [,as ownerof the property,inn exclusively conrraaing with licensed contractors to QTY. PLUMBING PERMIT FEE FT-OOD ZONE APN
an,,ma l the project(Sce.9004,Budneaa rad Pfofeasions Code:)The Contractors
License Luwdoesnatapply loan awacrofprolamy who builds or improvesthemon,and PERMIT ISSUANCE
whocontracts fcrsuch projects with acomracror(s)licensed pursuantto the Contractor's
Usama Law. ALTER-DRAIN&VENT-WATER EAO FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Ibis reason BACK FLOW PROTECT.DEVICE OUTSID; ES
SANITARY Y—N
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECE;IPTp
WORKMAN COMPENSATION SCHOOLTAX YN
hereby effiom thatl havcaceni6whe of consem to self-instars.or amniBcamof FIXTURES-PER TRAP RECEIPT#
nrkmvken'Crnnpensatinn loss nifiedrnpy thcreof(Sec.3800,Lab C.)which PARK FEE YN
Pal icy pll empinycepund this mlhTiO��_�� GAS-EA.SYSTEM-1 INC.40ITfLETS RECEIPT#
77 77 ,,�! /! BUILDING DIVISION FEES
C�o^yhnny GAS-EA,SYSTEM-OVER 4(EA)
U"Cenified copy s ro, fumis ed. PLANCHECK FEE
!❑ Cenified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFA SETRAP SOILS FEE
COMPENSATION INSURANCE
(This section nad not becompletcd ifthe Permit is(crone hundred dollars(S 100) SEWER-SANITARY-STORM EA.20pFT. ENERGY FEE
or lean.)
I crony that in the performanceuf the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECIR
of employ any person in any manner so m m become subject lr the Workers' PAID
Connarvation Lawsnf Califnmiu. Date WATER SYSTEMOREATING Date Receiplp
O z APPlictal
z NOTICE TO APPLICANT:If,aOcr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.ET.
Fbecome subject to Ne Worker's Compensation provisions of the Labor Code,you must TOTAL:
a > forthwith comply with such provisions or this pcmdt shall he deemed revoked. EELECMIC
a w
y CONSTRUCTION LENDING AGENCY
z 1 hereby affirm thm there is a construction lending agency for the parormance of r S�
U O the work far which this permit is issued(Sec.3010.Civ.C.) TOTAL:Lenders Name
0 ULenders Address QTY. MECHANICAL PERMIJ' FEE E1 cenify that 1 have read this application and sum that the above information is
acorrect. I agree to comply with all city and county ordinances and..state laws relating to PERMHT ISSUANCE FEE
Vj Noldingeenslrunion,and hereby authorise representativesofthis city toemerupontbe
U z ohne-mentioned propeny for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save.indemnify and keep harmless the City of Cupertino against
liabilllies.juit costs andenp nuswhich may inany way acerve against said City AIR HANDLING UNIT(TO Ig00)CPM)
I.<nn 'Lu se ger �g o is permit. q
AIR HANDLING UNIT(OVER 10.000 CFM)
Sigmrtyle motor, i Dam EXHAUSTHOOD(W/DUCI
PAID
AZARDOUSMATERIALS DISCLOSURE HEATING UNIT(TO I00,0001OU) Date Receiplp
Will the applicam in future building a,c'upum store or handle hagardaus mammal
as defined by the Cupertino Municipal Coale,Chapter 9.12,and the Health and Safety HEATING UNH'(OVER 100,000 BTU) DOTAL
Code,Section 25532(.)^
❑Yes 0 N VENTILATION FAN(SINGLE RESID)
BOILER-COMP DHP OR 100,0W BTU) n ISSWAUE DATE
Will air commutators
rs as building by do,
Am.Air Quality
Management
r j� 1 IJ
Dish i]air conuminanrs m defncd by th<Bay Area Air Qualiy Managemem BOILER-COMP(OVER 100,000 BTU)
❑Ycs C3No NEW RESIDENTIAL MECH. SQ.FT. DEC
2 1994
have read the hturdous materials requirements under Chapter 6.95 of the
Calibur is Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a lenam,that it is my oesponsibibly is notify the rillY VI- WrLllI INU
occupant of the requirements which must tc mei prior to Issuance of a Cenifcate of
Omapanay. \- ,
Owner or uuthoneed agent Dam 'TOTAL: ISSUED BY: r (O VW J
OFFICE