27674 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPRRTINOI IllLDING—ELL. RICA. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 2
7 C 7
BUILDING PROJECT IDENTIFICATION G V L�
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
UNIT# LOT to � a^ �J
t O ERSN ME: PIIONF.: U C rRACfOoo R'S ML': LIC NO:
s�— [ � G 'Sc NIC CONTROL.#
RCIII'I'.C'I'/L+ GNE iR: LIC NO: nA ADORT / ❑
6R5 q
(CONTACT: PILONE- QTY. 17LECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT MUCH
PERMIT ISSUANCE 1 1:1 PLUM❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL, JOB DESCIBPIION
pyoz Ihereby affirm that l an licensed underprovisionsof Chalucr9(commencingwith
ts100 Section lostim (Division Sof the Business and Professions Cafe,and my license is in PANELS
Oe LLIE fall force and effect.
U,CCI)yI Licenen Class Lw.N UPT0200AMPS
may Dare - Contractor 201-I"AMPS
ZOy Z• ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLO R AREA $/SQ.FT'.
O Z-0 1 urWersmnd my plans shall be used as public records.
r; W SIGNS ELECTRICAL
Licensed proteasioml
a O,I ano awmBP to..
DECLARATION SPIiCIA1.CINCl11'I'/MISC.
t�'OaU I hereby n (Section
Se Char 1 am exempt from the Courtrooms License Law for the
followF.LLOa whichingPronoun,apcouli to construct,
Pm,deomd.or Code: airy or county TEMP.MFf1iR OR POLE(NST.
which requires n permit re construct,al¢q improve,demolish,or mpaig any structure
<� that hor o,licensede,also urtan,vires mrosimrwie applicant fine Conamsuch etino Licete a se La smmment POWER DEVICES
Op thatheis licensedth Svoivmmeprovisionsof the Commmors License Law(Chapter
d p�' 9(wmmm�cing with Section]000)of Divisinn3af the Business end Profusions Code) SWIMMING('001.ELECTRIC VALUATION
❑m Proud he isexemp(therefrom and thebusixforthe alleged eacmpoon.Any violation of OUTLETS-SWITCHIS-FIXTURES
F Z G Section 7031,5 by any applicant for a permit subjects the applicantto a civil penalty of
not momthan ,.ftherohundred
rtydollars($em). NF.WRMIDENT'IALELECIIt _SQ.FT. STORIES TYPECONSTRUCTION
❑ othe wnernftthe
structurermnotyempinded eeswiNwed furale(See 044,8 Business
Pont
a will aathework,CMe 'fiire Cmusvir'.Ln,croe Lfw do forsale(ply to an owner
.. Professions Code:'fire ves t hereon.License Low aces col apply ns an owner of '
prop cnywbnbuildsorimprnvesthimprovnJentscent mendedorofh work lfonhmugh his OCC.GROUT' RIS.UNITS
tun empinycen,providW thotsuchimprovemcme=not imrndcd oroffcrtd forsale.If,
however,the buildingor improvement is sold withinone year ofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthe property,am exclusively contracting with licensed cmnruclurs to QTY. PLUMBING PERMIT FEE FLOODZONH APN j
nswct the project(Sec.]Mq Business and IMfcesions C(Ac)The Contractor's
License law docs not apply to an ownermproperty whobuildsorimproveatherean,and PERMIT ISSUANCE
whommrams for such projects with acomraclons)Iicenud pursuant Print Contractors
License Law. ALTER-DRAIN&VENT-WAT17R(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUISIDH FF.F..
SANITARY Y N
(Tuner Dale RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARCA,COND. SCHOOLTAX YN
❑ Ihereby affirm that l have a certificate ofcons<nrto self-nsum,or a certificate of FIXTURES PER TRAP RECEIPT#
Worken'Compensation lmumnceorn certifnl copy thwem(Sec.3800,Lab CJ which PARK FEE Y N
cnvennll employee's under this permit PA -CA.S -I INCA OUTLETS BUILDING
Putney _ ' i� BUILDING DIVISION ITES
... Company GAS-EA.SYSTEM- VER4(EA) PLANCHECK FEE
❑ Cer ified copy is hereby Bunished.
❑
Certified!copy is filed with the city inspecti division. GREASErINDUSTRL ASTE INTERCEPTOR GRADING FIR
CERTIFICATE OF EXEMPTIOI FROM WORKERS' GREASET'RAP SOILS FEE
COMPENSATION IN URANCE
(Thisseelionnced not be completed ifthe p Put is for one hundred dollars($100) SEWER SANITARY-ST RM PA.20017. ENERGY FEE
ar less.)
I certify that in the performance of the work or whiehthis permit is issued.lshall WATER HEATER W/VEN'1-AA.ECR
Pot employ any pennn in any manner so as o become subject to the Workers PAID
Gsmpensation Lews of Culil'omin. Datu WATER SYSTENUTREATIN Data Rocdpt#
Q Z Applicant
. Z 0 NOTICE 10 APPLICANT:IL after making thi Cenificnteof Cxemption,yoush Id EWRESIDENDIALP TOTAL:
F (/] baomeaabjem mthe Wbrkds Comprnxetinnp vsions ofinelabor Cod e,yoammt
ai 7 fonbwim comply with such provisions or this mdtshall deemedre k �� BUILDING FEE
W (� CONSTRUCfION LEN IN G ' V SEISMIC FEC
z I herchy affirm that there is a consvuctin,lending r I'he peformacP ELC TRIC FEE
O the work Por which this pemsit is issued(Sec.3 N],Civ.C)
4ndds Name z PLUMBING FEE �s
O F Lender's Address QTY. MLCUANICAL PERMIT FEE
V 1 certify thin 1 have rcud this application nd state that 1h above information is -
W correct. Iugree to comply with all city anA nn tyorainancm and state laws relal',n I'I?RMTf IS UANCG. - MECHANICAL ITEC
building construction,and hereby authorize rep esentatives of this city to enter alum the CGNSTRUCI'IONTAX
U Z above-mentioned property for inspection pu 91. ROR ADD TO MECH.
(We)agree m save,indemnify and keep amriess the City of Cupertino ngoias,
liabililea,j udgmews,c dsandex which n any wayacerueagainst said City AIR HANDLING UNIT(TO 10,1000 CFM)
nscquc matin Ihi oon.
AIR HANDLING UNIT(OVIiR l0bX)CFM)
Si mofA hcam/ mt r Dam EXHAUST HOOD(W/DUCIT PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"DTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
ua delined by t he Cupertino Municipal Cale,Chapter 9.12,and the Health and Surety IMATING UNI'1'(OVER 100,000111 U) TOTAL:
Gsde,Section 25532(e)? Vf?NTILAT'ION PAN(SINGER
13 Yes ❑No BESIDE
MOILER.COMP(3UP OR 10030X0 BTU) ISSUANCE DATE
Will the uconta manta s definnl by the Bay equipment orality Management
t P A 1 D
sazardnm air contaminants m defipcA by the Bay Area Air Quality Management -' BOILER�COMP(OVER 1 W,INN)BTU) �'
DistricO
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
I have read the hazardous materials romimmunts under Chapter 6.95 of the FES - 11995
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that ys
if the building Jnes not currency have amount,that it is my rexpnneibilirymnmify the oily ur h'
occupant d the requirements which must he met prior to Issuance of n Certifeme of 'rry/s
Occupancy. V
Owner or amhorizcd agent Data TOTAL: ISSUED BY:
OFFICE