27940 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILIHNU- ' (,IRI A, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27940
BUILUINI:DIVISION BUILDING PROJECT IDENTIFICA'1'I(IN
BUILDING
�ADDRESS:
��[� '_f I _ SANITARY NO. APPLICATION SUBMIITALDATE
(' I✓d 1 ' `Lff+ ( e L-II' UNIT# LOT It
OW/71150
W :RS N��A'M((��E: PIIONE: [l n CONTRACTOR'S NAME: LIC NO: (' IT/
01e t n d n I' /�c�� NIC CONTROL
• RCHITECT/ENGINF,ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERM19'ISgUANCE 3Ze00 IC�
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LAS
QWz, Ihereby grim that l am licensed underpmvisionsof Chapter9(commencingwith JOB DESCRIPTION
pAO2 Serums 7W0)of Divismn 3afihe Bavinexs and Professions Cade,and my license is in PANELS
=W
E full force and effect. /a--/r
F�,m License Class Lick UP TO 200 AMPS C ,Ts �M �ras(� .I�
may Dae Contreclor 201-I"AMPS V` Ill` V#k7 R(,
ZQNZ ARCHITE=DECLARATION OVER 100.9 AMPS SQ.FI'.FLOOR AREA $/SQ.FT.
0y,_C I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
,oe< OWNER-BUILDER DECLARATION SPECIAL CIRCUI'DMISC.
OaU 1 hereby affirm that 1 an exempt from the Connector's License Law for the
ty3ay Ibllowingremmm.(Section 90315,Bteinesa and Prafe.vsions Cade:Any city or county TEMP.MET ER OR POLE INST.
F"a which myuirea a permit m masted,.Iter,improve,demolish,or repair any amemm
rior m its irsuance,alsorequires theapplimntfor such permit to file aaigned ate6ment POWER DEVICES
W=< that he is licensed pursuant the provisions ofthe Comnal's License Law(Chapter
dap 9(cnmmencing with Section 9000)of Division Sof the Busincsx and Professiam Cede) SWIMMING POOL ELECTRIC
W M, VALUATION
Wor Seelmhe 131.5 by ayappomanf the ba.itxisforrbealleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES 0
I—ZQ Section their see hundred
,($50rmit subjects the applicenno acivil penalty of - W 7S� VD
not more than five M1undrcd Jnllars(8500). NEW RESIDI?NTIAL ELEITIR _
KFo ❑ Lasownerofthe propeny,ormyemployecs with wagesastheirsole compensation, SQ.FT, STORIF_S TYPE CONSTRUCTION
a3LE will do the work,and the structure is not intendedorofferal forsale(Ss.]I)w4,Business
and Professions Code:The Contractors License Law docs not apply to an owner of
propedy who buildsarimpmva thetean,and wmdoes such warkhlrmelfonhon,til is
own cmployces,pmvided thdsuch improvements are notintendederoffered formle.If. OCC GROUP RES.UNITS
however,the buildingar improvement is sold within one years fcampletion,the owner-
builder will have the burden of that he did not build or improve purpose o TOTAL: t a
proving prove for f
Ic TY. PLUMBING PERMIT
Las the project
(See.
70LI .Business
an contracting with de:)The Contractor's Q FEE Fl.00D ZONG APN
conLicense the oesnal(Sec. ono Business and Professions Cade)The Con on,and
whocaelawd«smtapplywunowncrofprnpenywhosed pursuant
thereon,and PERMIT ISSUANCE �aVD
whonse La tsI'ortach protects with acontrutorts)licenced pursuunuothe Convacmr's
License s Law ALTER.DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owe. M xx oe_
SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOL SAX RECEIPT# N-
❑ Ihercby affirm lhalhaveaccnifica¢of cnnscnno self-i�uum,nracenificam of FIXTURES-PER TRAPRECEIPT'#
Workets'Compcnvtlon Insurance or accnifed copy theteafSec.3800,Lob C.)which 0 70 0 PARK FEE Y N
/ rovers all employee's under rola permit.
Policy M GAS-FA.SYSTEM-1 INC.4 OUTLETS RF,CEIPT#
BUILDING DIVISION FEES
Company
Cenificd copy is hereby famished GAS-EA.SYSTEM-OVER a(EA) PLANCHECK FEF,
❑ _
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRLWAST INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM,WORKERS' GREASETMj I s. SOILS FEECOMPENSATION INSURANCE
(This section need not be completed B nue pnmil is(c'Ime hundred dollae($100 SEWER-SANITAR - T EA.200FT.1 ENERGY FEE
or le .) 'I:
I certify that in the Nnosmance of the work Por which this pe.his issued,lshut s WJTFR HFA ' ENT/ELECB
oat employ any person m any rammer so as to become subject to the Waske PAID
z
Appliaam Cnmpcnsminn Laws n(C.lifomia. Dae A Y " Date Receipt#
Q "t
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,youi o RE IDEM IAL PLMB. SQ: T.
res
became abject ttaoimt
o the Workers Conlpenxon powiss of the Labor Cade,you mtm TOTAL:
forthwith comply with such provisions this shall be'deemed evoked.e '
_ or perm _..,...,...,.:..•.•. .• BUILDING IEEE
,l
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE O #SQ
Z Ihereby.ffths0
rn m there is a covuction lending agency for the performance of
(� O the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL: a ELECTRIC FEE / e
Lender's Name b [
0U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE e�a
W I certify that I have read this application and sate that the above inhrrnation it
6. nrrea. l agree to comply with all city and county ordinances and state laws relating to PE IT ISSUANCE MECHANICAL THE
<A buiddingemistruction,and hereby authorize reproentsevesorths city m enter upon the
U z above-mentioned property for inspection purposes. ALTE ORADDTOMECIL CON$TRUCrIONTAX
(We)agree to save,indemnify and keep handess the City of Cupertino against
Iiubilities,judgmems,costs and expenses which may in anyway seems,against saidCity AIRIIA LING UNIT(TO U),"CPM)
//--��eyuence or the granting of this permit.
/ I r/ /
Y� I_/7 SLI AIRHANDL G UNIT(OVER 10,000 CFM)
SignemfrcoApphcanVeam
Com "Date 'eJ EXHAUST HOO /DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1 BTU) Dee Receipt#
Will she applicant or future Municipal
C occupant store or handle Health a material
az reline]by the Cupcnino Municipal Cale.Chapter 9.12,mal Health sad Safety HEATING UNIT(OVER 100, U) TOTAL:��[xv
Gila,$CetlEl 25532(n)Y
❑Yca ❑No VENTILATION PAN(SINGLE RESID)
Will theapplicant mfumre mildingrx:cupanmseeyuipmentordevieca which emit BOILER-COMP GHPOR 100,000 BTU) ISSUUpANCEEp��DATE
• hemsdous air comaminams us defined by the Bay Asea Air Quality Management BOILER P K 1 0
District? COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDEtITIALMECH.
1 have and the hazardous ma¢riuH reynire5533 under Chapter understand
nd the
APR 17 1995
Celifomil inStealth&101 cur Code,Sections 5505,t it is and SS34. I understand Nat
ifthe building does acsnotcuncmlyhave atcns, that itis tmy o
to notify the CIII tar Vu�Cf11 IIVU
ocaupam of the tryuvcmena which must be me prior to issuance of a Certipane of
(kcupancY.
PI
Owner or amhanzul agent Date TOTAL: ISSUED s V�� •l✓CG
OFFICE