27986 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOICH¢crNa-RCR� A. PERM]I'NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECTIDENI IF'ICATIIIN 27986
BUILDING ADDRESS —{y//� TT g^�, ` R11`````^^` )) SANITARY NO. APPLICATION SUBMSTAL DATE
��F\ 1 ' "' L.-) RiI'N LOTH
O PHONE: CONTRA NAME: LIC NO: ♦♦♦
N/C CONTROL e
RCInm /E.NGINEF.R: LIC NO: ADDR E -7
:)NTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECT' PLUMB MECH
PIERMI'1'ISSUANCIi �• ❑ ❑ El
LICENSED CON'I'RAMOR:S DECLARATION AI'YLIANCES-RGSIDENTIAI.
QWz I hembyaffitm that l am lioureedundcr provisiomof0ria 9(commencing with JOB DESCRIPTION
u100 Sccai"n 7000)of Dlvldon Sof the Bminess and prom" +de.and mylicense is in PANELS
FC W` full fame and effect.
F j� hicemc Claes Lies# UP TO 200 AMPS ,
tn« Date - Comate 201-Fort AMPS
F y-,{ ARCHITH DECLARATION OVER["AMPS SQ.FT.FLOOR�AREA 8/SQ.FT.
ZOtn� l understand mypla ,h, uscdas public records /♦�IIyV(/s
Oz !od
r y pp w SIGNS(ELECTRICAL
QYLj Licensed Oahe `
W Mix< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 hereby Bim+thin I um exempt from In Contra, 's Licenseaw for the
tW ay fullowingremo ISectionl03L5,Buainee end Pro m C( nycitmummy TEMP.MEIFR OR POLE INS].
L-�OQ wI, h uirea a c
m+it to cera 6"Imr,'a , lmlureet I'h, rcpuir an rc re
5'}� priorloibusuanec alsorequires r t sue mduofileang summcm POWER DEVICES
,,=<0 that he i.Iuend p ssetam a ahe m mm
oemr's Lice .aw(Cha do r
aXoec 9(comrmuciegwith tion]( o3oftbe Business fesslons Code) SWIMMING POOL ELECTRIC VALUATION
Wim onhmhckesemptther } a infortheallegedexe ton.Anyvinlationof OUTLiifS-SWITCHES-Fl%TURES
FZG Section ID3L5bY mYap 'carrier pe +it xublamc tm
thee acivil pcwltY of
$
2p wnarcthanufive hundred nllars( NIEWRLSIDIENTIALELECIR SQ.FT. STORIES TYPE.CONSTRUCTION
a'to ❑ Lasownendd+epnspenormyemploymow+ agewastheirsolecoarpoinaeon,
y3„ wllldothework,undthe some, a notimendedofeted forsele(Sm.7044,Business
mull'-fessors Code:'HI Co radar's Lice Law does not apply to an owner or
priverywhtindidsorimprov esrc hidocssuchwork FS
himselforthough his OCC.GROUP R .UNITS
employees.prvvided that suchmenrsarenmimenJCJ andfercdfarsale.If.
however,he building or improvement is sold within oneyeafofcompletion,imowncr- T T
builder will have the burden of proving that he did nut build or improve for purpose of
side.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[II,ax owner of tM1"propeny,am cxdusivcly mmraming with licensed amtaetorsm
construct the prom(Sce.70al Business and Profcfeionf Code:)The Contfucar's PERMIT ISSUANCE
Lken,,L"wdocs not apply to an owne,of propeny who huilds m impaveathercon,and
whocontracts for such makers with a commoners)licensed pursuant loithicowALTER-DRENT
AIN&V -WATER(EA) FEE SUMMARY
Liccnec Low. ( a
❑ I em exempt under Sec. ,B P C for t s P BACK FLOW PROTECT.DEVICE Ol1TSID;FLI:S
SANITARY Y N
Ower DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT p
WORKMAN COMPENSATIOWDLk SCHOOL TAX Y N
❑ Thereby alflrm that lhave ucenificutc of ensure,n ace cateopIXTURI3-PERTRAP RECEIF'MWmkcn'Cnmpcnsation humreacemiles,ificdcce.381p Leh .)which PARK FEE Y
RECEIPI'p
Povers all nnployec's under tl+is pcnnit. GAS-P,A.SYSTHM-I INC.4011T1 ' S
9licyp BUILDING UIVI ION EHS
Company GAS.EA.SYSTEM-OVER 4 7 PLANCHHCK FEF.
ElCenified copy is hereby famished.
❑ Ceniticd ico,is Elcd with the city inspcm division. GREASE/INDUSTRL W TE INTERCEPTOR GRADING FIE
CERTIFICATE OF IEXEMPDON OM WORKERSGREASETRAP SOILS EEE
COMPENSATION INSURANCE q
(This section need not be completed ifthe permit is for one hundred dollars($100) SEWER-SAN ARY-STORMEA.20(ljp
FEE V
or less.)
I cenifythat I.the permanumm.fthe wmkfar which this permit is issued.)shall WATER TER W/VEbfT/ELEC`SR
nm employ any peon. in any manner in as a become subject w the Workers'
Compeneation Lawsaf Califomia. Dam— WA SYSTHM/I'REATING ReceiptIf
Q Z Applicant
NOTICE TO APPLICANT:If,after deft Cenifica¢of Exemption,you should N RESIDENTIAL PLMB. SQ.17. 'TOTAL:y becomesubjmm@eWorkors Coaapemmint provisiarsof the Labor Code,you mustG ITEH7forthwith comply withsuch pavlsions m this permit shall be deemed revoked.QCONSTRUCTION LENDING AGENCY FEEZ I hereby affirm that there is a construction lending agency forthe performance of UOthe work for which this permit is issued(Sec.309],Civ.C.) TOTAL: C FEEfender',Namc NG P�' Lenders Address Q'I'Y. MECHANICAL PERMIT O (1 1 crtify that I have read this application and state that the above information is ICA HEcorrect.l agree us comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE
building construction.and hereby cent representatives of this city m enter upon theCTIONzbove-mnaionul property fronspectin purposes. ALTER OR ADD TO MECIL
(We)agree m save,indemnify and keep handles,the City of Cupertino againstIlubilities,judgmenu,enstsu eases whichan,in my way scmueaglnm fond City AIR HANDLING UNIT(TO 10,0010 CFM)
inconsequence he mg ofJ�ii tit.�Cs 2AIR HANDLING UNIT(OVER 10,0110 CFM)
J'Signanoc Applient/Contractor Date E%HAUSTHOOD(W/DUCI)HAZARDOUS MATERIALS F: IIEAIING UNIT(TO 100.000 BTU) Dale Recei
Will evpplicam orfmure building occupant amre or handle bafsrdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health an (X1d Safety HEATING UNIT(OVER 100, 0 BTU) Tf>T^ '
Cede,Svmirm 25532(a)'2 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR 1110.011(1 BTU) IS S(jN`LCE:ATE
Will the applicant or future buddingxcupa"t usecquipment ordevices which emit n^ /� ! D
amadous air conformations as dclined by the Bay Area Air Quality Management BOILFR.COMP(OVER 100,0110 BTU) •,IQ
IAL MF:CFI. SQ.FT.
49District? El Yes ❑No NEW RESIDF,MIF�( Y
19
' g
I have read the hafurdous amends requirements under Chapter 6.95 of the eir'r ear Jr
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that LUf'tk .
if the building does not currently have a tenant that it is my responsihility in notify the
cupant of the medicaments which must bo mel prior to issuance of a Certificate of
Occupancy. knvli
Owner or andmrized agent Dam ISSUED BY:
OFFICE