27145 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFR.TINOtJ1l,UN".ELhCrRF7TL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27145
BUILDING.DIVISION BUILDING PROJECT'IDENfIFICA'1'ION
ILDING ADDRESS:`, kms] ^ SANITARY NO. A/PPLICATIONSUBMITTALDATE
T1 (� A
M� LOTk ( L`
RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
V C •�Swt -ZSZ29 �' N/C ON IK L0
CHITECf/ENGINEER: LIC NO: _D ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE �j 11
LICENSED CONTRACfOR'SOns ofCh TION APPLIANCES-RESIDENTIAL �f TOB DI�
iowzUO2 IhereiryeffDi Nal malicensedBusiness
and isionsions Coaer9(co mmencing with Q
1x100 to I fan a and effect, on 3 of she Business and Profusions Cade,and my licenx is In PANELS
cut KFFK,, {{'''' full forte end eRat �e
EZµ) License Class Lick UPTO200AMPS
m1�.'y Date Convector 201-IOW AMPS
OZ—Zs. ARCHITECTS DECLARATION - OVER HIM AMPS SQ.FT.FLOUR�/iE/�Q Lax�Q Fn
02•�p 1 undersand my plans shall be used a public records. r r% L x
1-,y , SIGNS ELECTRICAL
sy Lrtensd Professional
4K�V OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oa 1 hereby affirm that 1 am exempt from the Contractor's License Lew for the
W 3 py following mason.(Section 7031.5,
Business and Professions Code:Any city or county TEMP.METER OR POLE KIST.
E"aJy which requires a permit to construct,than.improve,demolish,or rtpur any someone
U 7 pnorto its issuance,also requires the upplicamfor such perrnitto file asiam
gned smem POWER DEVICES
�+�'OO that he is licensed pursuers the provisions of Ne Consommes Lt.law(Chapter
�aMp)„a
ff 9 fcommencing with Section 7M)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is cxempnherefrom and the basis far the alleged exemption.Any violnionof
Section 7031.5 by an licam for 1 PDi an P y OUTLETS-SWITCHES-FIXTURES 7b���
any permit subjects the I c a to e civil nut of 0
C`Z. amore Nanfivehandeddollars yempl NEWRESIDENTIALELECTR S .FT.
yCo n❑ eche wrk,andepmperty,anmyemployecswithwageassalc(Sele compensation, Q STORIES TYPE CONSTRUCTION
,3`..° and Pr Newons Code
Des wmisnatin¢nensedled Law d(s not apply to
Business
and property
wha ds Cde:The vea vectors License law does or apply to an owner of
pmpenywhob,provirimpmveathereon,andentsm,ssuchwmkhimxlfar throughhis OCC.GROUP RES.UNITS
howemployees,lmvided Nm such improvem<nthin neyear dcda pletiod fm We.if,
however,theave egorimpro.ememis soldwithinaneyea o1 improve far
pumpam r' T
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ I,xowncroftheproperty,amexdusivelycanvxting with l¢<vedcontrectorsm QTY, PLUMBING PERMIT FEE FLOOD ZONE. APN
construct the Project(Sec.70,10,Business and Professions Cde:)The Contractors
License Law docs not apply to an ownerofpaperry who builds m improves thereon,end TISSUAwb;
whoconbvcts forsuchpmjars with acanvscon(s)licensed pursuit the Contactor' ALTER-GRAIN FEE SUMMARY
License Law. D WA EA)
❑ 1 am exempt under Sec. ,B&P C fm this re np 1
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Dae DRAINS-FLOOR,ROOF, CONU. RECEIPTM
WORKMAN COMPENSATION DECLARATION , , SCHOOLTAX YN
I hembysffttmthai Tlwveattnifice ofcoruentmsclf-insum,orac 6 amof FIXTURES-PER TRAP RECEIPT'
ohms'Compensation Insurance caracertifd copy thereof(Sec.3800,Lab C.) hich PARK FEE Y N
n
coveall employee's under this permit. t GAS-EA.SYSTEM-1 INC.4 OUTLETSRECEI M
PolicyN BUI INGDIVI ON ,ES
Company GAS-EA.SYSTEM-OVER 4EA
ElCmifid copy is hereby fumisled. ( ) PLANCHECK FEE
❑ Cmifid copy is fled with the city inepmtldn division GRI3ASFJINDU$TRL "INTB OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
(Thio secaionnad not be completed ifthe pemtit is forone hundred dollen(SI00) SEWER. T Y- (.200FT. ENERGY FEF.
orlms.)
I ccm"ad in the perfomance of the work for which this permit is ixud,I shall WA RH TERWIV ECTR
not employ any person in any manner so as to become subject to the Workers' jfV
_ pplp
Z Compensation Lawsof Culifomia. Date W ER SYST TING em Receipt#
Applicant
zOzF-I0 NOTICE TO APPLICANT:ILafill making this Certificate of Exemption,you should ESID PLMB. SQ.PT. TOTAL:
t' ti became subject to the Workers Compensadaa provisions of the labor Cde,you must
Fal , foMwith wmPly with such provisions or this Permit shall be dated revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
V z 1 hereby affirm that them is a construction lending agency for the perfomunm , ELECTRIC F E
O the w
work for hich this pemdt is ixud(Sec.3097,Civ.C.) �w
" 6 Lenders Name
0 Leaders Address QTY. MECHANICAL PERMIT FEE PLUMBIN FEE
1 mrlify that 1 have mad this application and sate that the above information is
a correct.In me to comply yen y g MECHANI AL FEE
g py wileyaus and mNnesoffl dsem law. to PERMIT ISSUANCE
U) above-gconstrectionand herebyeuthoi pmprexnudvuof thio citymeater upon the
L) z ebov(We).9.progenyfor inspection purposes. ALTER OR ADD TO MECH. CONSTRU ION TAX
(We)agree m save,indemnify and keep harmleae the City of Cupertino against
liabil” dgmenm,cosuandexpe which m,yinany way aecme against said City AIR HANDLING UND'(TO 10,1100 CFM)
anxyuence of thug o --"
A-I AIR HANDLING UNIT(OVER 10,000CFM)
igrtamm of APplicent/Cmarector purr EXHAUST HOOD(WIDUCry
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Oxe
Will the the C,nnt or xmirso Mure nicipal
Code,ng Chapter 9,12,
or handle hHealthand Safety HEATING UNIT ICYM t00,0110 BTU) AL:
al
as defined by the Cupertino Municipal Code,Chapter 9.12,sod Ne Health and Safety
Cde,Section 25532(q?
13 Yes ❑No VENTILATION FAN(SINGLE MID)
Will thea liuntorfummbuildin mcu BORER-COMP(3HP OR IW,000 BTU) ISSU NC ATE_
PP 8 panmxequipmemmdevicu whiMcmia
eurdous air contaminants as defined by me Bey Am Air Quality Management
BOILER-COMP(OVER 100,000 BTU)
Ontrict?
C3Yes ❑No a NEW RESIDENTIAL MECH.—SQ.FT.
I have reed the finardous materiels reyuirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505,25533 and 25534.1 understand that ®CT 1 1994
if the building does not currently have a armed.Nat it is my respouibiliry to notify no
occupant of the reyeir mems which must Ito met prior to issuance of a Certificate of
Occupancy.
Owner or amhorimd agent Data
TOTAL: ISSUED BY: aaklrkrL 'NIU
OFFICE