27651 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO InFoLtrillsi-I.Lboll.11AL PERM1rNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27651
BUILDING DIVISION BUILDING PROJECT IDEN'rIFICA1 HIN
HULLOING AUURESS: Al SANITARY NO. APPLICATION SUBMITTALLDATE
12 P'rA UNffa 1 LOTH
OWNERS NAME: PHONE:'73�_C/71 CONTRACTORS NAME: I.IC N�`L3 N/C CONTROL#
® RCIIITECI'/ENGINEER: I� LIC NO: II ADDRESS eT
CONTACT: ICe uw. o .y=$!„PuolvE. — QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
q00 A6,46
R' (p' BLDG ELECT PLUMB MECII
K9 PERMITISSUANCE 1:1 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Oa'Z Iherm affirm that l am licenced under provisionsm'Chapter9mommencing with JOB DISCRIPI'ION
POO Scmion](101 Division 3ofthe Busdnessand Pmfcmions Code.and my ice.is in PANELS
ym� full force and effects s�
6jW License Class _ Lica - UP TO 2M ANIPS
v~iQd Date Contrutor (Y r. 201-IMAM
F Z) ARCHITF,CI-S DE ARANO �v1S OVER 1000 AM SQ.FT.FLOOR ARTA S/50.IT.
Z.Ovt Iundersmadmypluns shall be uscdm bli<rcmMs.
Oz—M SIGNS ELECTRIC
QY$jLicensed F'roPossional
C WQ OWNER-BUILD RDECLARATION SPECIAL CIRCUIT C.
eOaO I hereby uffim that I am cxcmp from tM1e ComnnMs Licenu law for
FLLOa following rcaum(Section]OJLS,Bu cru and Professions Code:Any city or corona 'TEMP.METER ORPo (NST.
.] which rtyuires a permit to construct, Iter,improve,demolish,or repair any,structure
�ro}�. prinrm ire,issuance,also rtquissth PPlicam for such pemiuo filensigned usmenh POWER DEVICES
00 that he is license) sat to the visions of the Commdnrs Li,mm Ln Cha ter
pursuant P SWIMMING POOL EL VALUATION
ayo� 9(commencing with Section] ofDivision3ofthe Businessand Prof
^y mthmhciaescmpnM1erefmms diebasisforteallegcdexemption Ia of OUTLETS-SWIT ES-FI RES (•�.kn ��5, n�
Saation V031.5byanyapplic tfnti,mmirsubj the aPPlirarnm . peneItY of
Q nm more than five hundred ollars(4500) I
F. ❑ NEWRESID ALELECTR SQ.FT. STORIES TYPECONSTRUCf10N
K�pro ❑ I,asmwonndmepra rhy,nrouyeiii ages ecompens t
pW-3� willdnthework.andth mucarmisto imen offend for ecA0a4,Buv s '
and Professions C :The Cnntreclor's Lim se law dfy����t app man ow of
propenywhobui rt provestncrcon 9 dmssukh�$kTtmsdfor thro hM1ia r
employ 'Provo Natsuchi ants t t doroffertdfor e.IL OCC GROUP RIS.UNITS
however.the wilding or ma'seem
em Liss Id wit n car ofcompletiart nsim, TOTAL:
builder will n e the burden t, 'bid he dt�a m improve fur uryau of
aide')' \ QTY. PLUMBING PERMIT FEE ROOD ZONE APN
❑ I,uowncn'hcpfnpa xclusivelyconductingwithlicenset mmctorsm
on.atuer he pr.jet 'cc.9044, e ss and Professions Coded Cantncmr's
Licenu Ldw does not up hoedown opropenywh.tudid.mirupou esthemon,nnd PERMITISSUANCE
whosommiNfm.suehproj with eco umor(s)licensedpursuanu the Coammon's
License Law. ALTER-ORAL &VEIN'T-WATER(EA) FEE SUMMARY
❑ l om exempt under Sec. ,B& C for this uaaon BACK FLOW PR ,Cr.DEVICE OVI'SID;I-EFS
SANITARY YN
OwnerDat DRAINS-F100R,R F,ARG.CONU. RECEII`F#
WORKMAN COMPEN TION DECLAR ION SCHOOI.'fAX Y N
❑ Ihcrcby nlfirm rhetl have accnificate o' onacnt to xlf sort,roncMific."id' FIXTURES-PER TRA EI
RECPT#
m
Wkmi-Cotnmio
perenlnsumncc nraccnificd thereof ec.3g(X4Lab C.)wnich PARK FEE Y N
coverall empl Y Mrthis permit RQ GAS-EA.SYSTEM-1 IN 4OTTLETS RDIVISI N
Policy# 4-•S BUILDING DIVISION Fli1:S
Cmapany GAS-EA.SYSTEM-OVER (EA) PLANCHECK FEE
❑ Cmifiedcopyishertbyfumished.
Certified copy is filed wiffide city inspection division GREASE/INDUSTRI.WASTE TERCEPfOR GRADING FEE
( CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS ME
COMPENSATION INSURANCE
I ('Unissecuannem not be completed iftbe permit is fortune hundred dollars($100) SEWER-SANITAR)-STORM F, .20017. ENERGY FEE
or less.)
I certify that in the perfonnenu of the work for which this permit is issued,(shall WATERHEATE W/VENT/ELE
not employ any person in any manners as m Isco app�a t 1
9 the Worked' PAID
Z
Compensation laws of Califnmia. DI o ME", WATER SYS 3MiTREATING Dmc R cipt#
J?tu.
Z0 NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you should NEW RFSIU M'IAL PLMB. TOTAL:
I" u become subject m the Worker's Compauntion provisions of the Labor Cade,you must
a > forthwith comply with such provisions or this Permit shall be domed revoked. BUILD(' .E
1 [� CONSTRUCTION LENDING AGENCY SEISM1 .
U z I hereby affirm Fred is a construction lending agency fm Be perfmmmnce of
Ne work for which this permit is issued(Se,.3111,Civ.C.) TOTAL: ELECTRIC FRIi
headers Name PLUMBING FEE
U" F Lender,Address QTY. MECHANICAL PERMIT FEE
V I certify that I have read this application and sun Nm the above information is MECHANICALIA'
correct. I agree to comply with ml city and county ordinances and Stam laws relating to PERMITISSUANCE
U7) building aonxvumion,and hereby amhoriu reptesenmfives ofthis city to enter upon the CONSTRUCTION TA
U Z above-mrmahmed property for inspection purposes. ALTER OR ADD TO F.CIL
(We)agree on save,indemnify orad keep hmmlies the City of Cupertino againat
habilidea,judgmenm,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT 010.000 CFM)
a.con,ftreacc of the granting of Nis permit.
AIR HANDLING UNIT( VER I0,00q CFM)
S,prourcnf Applicant/Comnctor Dmc EXHAUST HOOD(W/DU PAID
HAZARDOUS MAI ERIALS DISCLOSURE HEATING UNIT CFO IOOM TU) Date Reve #
Will the npplicwn or fuwrc huilding cecupmn stow m hmJlc hazardous memdal TO'AL:
as defined by the Cupcnin,Municipal Cole,Chapter 9.12,and the Health and Safety I IEA'rING UNIT(OVER 100.000 U)
Cale,Scair 25532(#)? VENTILATION FAN(SI EBI( D)
❑Yes ❑No
ISSUANCE DATE
Willmeapplicmnurfumubuildingoccupantuue uipmenmrdeviceswhichemit BOILER-COMP(3 OR 100.M D
as Nom air sanatoriums as defined by the Bay Arca Air Quality Management BOILI?R-COM (OVER 100M BT ) pa;; (�
>isam? r K
❑Yes ❑No NEW RESID IAL SUCH. SQ.FT.
1 have read the hazardous materials on uiremems under Chapter 6.95 of the DEC 14
Califomia li It &Safety Cod,,Smtions 25505,25533 end 25574. I understand tam
if the building does not cunemly have a motor,that it is my responsibility to notify the
seapant of the ,ant.wmeakma t vie mel pnnr m issuance of a amfie m of
ooeupaney. D ` u1lU
Owntt nr anmodae igen `J`� 1 Date
TOTAL: ISSUED BY:
OFFIC
Cites of Cupertitw
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply with Section 1210-a of the Uniform Building Code.
Section 1210-a requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will, be installed, mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used for sleeping
,• purposes. If existing smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have smolke detectors
installed that do comply.
ADDRESS: � � fir-
PERMIT NUMBER:
HOMEOWNERS SIGNATU o
DATE:
winword/smkdet
I