27307 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOLIBN[i-KLKU rRICA L P`RMITNO. /� /k
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /7 ` O7
IIUIIAINGPROJECT'IBENTIFICA'noal L 1 �!
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE'
/ Q
VSeQ�, 12 UNITN � LOTH '
O ER NAME.: PHO CO R O "NAME: LIC NO:
NICCONTROL
RCHITECI'/IIJGINEER: LIC NO: DDRESS: r ❑
:OM'ACf: PHONE: Cwa 3! "s-.y T *t y'r' '. .. C•
QFY,ugi EI,FGTRIC PERMIT" FEE BUILDING PERMIT INFO
- BLDG ELT PLUMB A`Fqji
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB CRIPFION
Matz Ihereby affirmthm l amlicensed under provisiomofChupter9(commenciagwith
P102 Section 7"t of Division 3 ofmc Business and Professions Code,and my license is in PANELS Now
Licenoxund aflb UP TO 200 AMPS
H W Dat hlc,g
6a Omc Convecar 201-IOOOAMPS
ZOyZ' ARCHITIiCI'SU TION SQ.FT,f100R AREA
02.• lundersand myplansshallbeuseclaspublicemords. OVER HXR AMPS
PZF- SIGNS ELECTRICAL
�YA Licensed Prefeasionnl
Ok! OWNER-BUILDER DECLARATION SPECIAL.CIRCUIT/MISC.
OiF I hereby n.(Se thm 1 am exempt from the Cessions Cs License Law for the
W3oy following reason(Seetico]031.5,Businusand .A,datmne Care;Any city or county TEMP.METER OR POLE INST.
W W 0y g which requires.permit re conawct,olmo nt Far such
demolish,nr repair any swnurt
K�¢f pannoi¢issuance,d,ou 1.th the appliumfdreuchpnmo.File asigned".(Chmeo POWER DEVICES
K�G pC that he is Lice.w h Sects t to the provisions of the the H.,ors Litems Lew(Chapter
L54d eLL 9(commencing with Section]100)af Division3of Ne Businai and Profusion Cale) SWIMMING POOL ELECTRIC VALUATION
pl,_rn or that he is exempt herefrom and the basis for the alleged exemption.Any violation of DUTLBTS-SWITCHES-Fl%'1'URES
4 Section]031.5 by any applicant for o permit subjects the applicantto u civil penalty of
not more than li to lmndmd dollars($500). .
p ❑ 1,asownernfthcpmp Ay,ormyemplayeeswithwagesastheirsolecompensatiNEW NCSIDCNTIALELECIR
an. SQ PT. STORIES T'PECONSTRUCTION
y cO will do the work,and the structure is not intendedoroffered farsale(Sec.7044,Businus
and Professions Cale:The Cammnmrs License Law does not apply to an owner of
propsnywhobuildsorimpmvesdamon,and whodoessuch work himselfor through his OCC GROUT' RFS.UNITS
nemployees,providedthutsuchimpmvements enotimmndaloroffendforsale.If,
however,the building or improvement is sold within one year ofcompletion,the owner. TOTAL.:
builder will Lave the burden of proving that he did nor build ar Improve for pmpax of a
sale.).
❑ I,os ovocrol the property,amexelusively contracting with licensed cont amm QTY• PLUMBING PERMIT FEE FLOOD ZONE APN
conwm the Projat(Sm.70a4,Business and Professions Code:)The Conmetoes PERMIT ISSUANCE
Liansc Lew docs oat eppl y a an o weer e I propmy who bu i Ids m improvesthereon,and
who contracts forsuch pri with accountants)licensed pursuant in the Canwcmr'e
License Law. AI'ITR-DRAIN&VPAT-WATER(FA) SUMMARY
❑ [am exempt under Sec, ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTMDE FEES
SANITARYN
Owner DateDRAINS-FLOOR,ROOF,AREA,COND. RE IPTp
WORKMAN COMPENSATION DECLARATION SCHY N
❑ Ihembyaffirmthatlhaveacenificamofwn tit elf-insum,orac iricateof TA% RECE g
Worken'Compensmien Insurance or a certified copy thersof(Sm.3800,Lab C.)which FD7URI?S-PER TRAP sp Y N
cn ell c¢tNtsyaukwde{tMcpemt GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CE p
Pollcyg Ir\(1l�CJ '1�1}}1��110 BIl GDI IONpfili5
Compaay iia.} S _ GAS-IA,SYSTEM-OVER 4(HA) t .ANCHECK 31
cnifiM copy is hereby famished.
Certified m,is fled with the city inspection division. GREASNINDUSTRI WASTE INTERCEPTOR GRADING ', g
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SO
COMPENSATION INSURANCE
(This section need not be completed fthe permit is fortune hundreddollan(SIM) SEWER-SANITARY-SI'ORMHA,200FT. I+ E
orless.)
I candy that in the performance ofrhe work for which this permit is issued,I shall WAFERlf1ATERW/VFAI'/E1.1?Cl'R
Am employ any person in any manner so as to beeome mbjeet to the Workers' PAID
Compensationlawsof Califomia. Data WATER SYSTEM/IREATING Date Receipt
p Z Applicant
Z 0 NOTICE TO APPLICANT.If,Ant,making this Cerdficateof Exemption,you should NEW RESIDENTIAL PLMB. SQ,IT. TOTAL:
F' (q become subimt to the Workers Compensation provisions ofthe Labor Code.you must
forthwith comply with such provisions or this permitshall he deemed revoked. BUILDING FEE
[� CONSTRUCTION LENDING AGENCY SEISMIC FEC
VZ Iherebyaffinn Nat there is a construction lendingagency far the performace nof
O the work for which this permit is hound(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
lenders Name
0 F Lenders Addmas QTY. MECHANICALPF.RMIT FEE PLUMBING FEE
L) I cenify that I have read this application and stem that the above informmian is '
correct.l Allow to comply with all city and county ordinances and state laws misting to TPCRMIT ISSUANCE I MECHANICAL FEE
building construction,and hereby authorize representatives ofihis city to enter upon the - - CONSiRUCTION'TAX
7
V C obove-meoioned Expertly for inspection purposes, ALTER OR ADDTO MECII,
We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitiu,judgmrnts,consandexpensuwhichmayinanyweyattrueagvnrsaid City AIR HANDLING UNIT(TO 10,100 CFM
crime the,r ti of Is emal.
AER HANDLING UNIT(OVER 10,000 CFM)
renAppliunnr/Contractor F Up, EXHAUSTHOOD(W/DUCT)
AID
HAZARDOUS MATERIALS DISCLOSE) . HEATINO UNIT(TO 100,000 BTU) - Dote Receipt p
Will the applicant or future building occupant store or handle homedous material HEATING UNIT(OVER IW,fXIII BTU) L
as defined by the Cupertino Municipal Cale,Chapter 9,12,and the Health and Safety
Code,Section 25532(a)l VE ILATION FAN(91NOLI:RB$ID)
❑Ycs ❑No
Will the applicant nr futurehnilAingnhnpum useeyuipment ordavices wbich emit
LEE.
(311H OR I(XI,(X1110t'U) ISSUANCE DATE
suzardous air comaminums as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID
iso-im?
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IF.
1 have read the hazardous materials requirements under Chapter 6.95 of the �w 081A
California Health&Safety Code,Sections 25505,25533 and 25534, I understand that I I9
if the building does not currently hava n tenant,that It Is my responsibility to imply the IL
occupant of the mymossronu which must In mm pnar us issuance of a Cenifcate of Ur LVf ll;LIN
Occupancy.
Owner or authorized agent Data TOTAL:f43,jDn ISSUED BY.
OF IC