27055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIJPERTINO -FI.F.CTRTCA' PF:NMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27055 C 5
BUILDING PROJECT IDENTIFICATION J J
BUILDINGAAI )R SS^a: RA
A TA `1 SANI'I'ARYNO. APPLICATION SUBMITTAL
DATE:
1`w ' `•'e W RA �\Tl YE: UNITN LOT#
O :�S��yyy� Pt7O3C7 C ,AfCwT'OR'S NAME: LIC NO:
cc�^ 5S N/C CON]Rol.p�
I<;HI'IL 1/1 ISGINEER: ILIC N0: DDRES: a /�
:ON'l'gCI'; PHONE: a BUILDING PERMIT INFO
QTY. LLEGTRIC PERMIT FEE
' �.I�� BLDO ELECT PLUMB MliCll
V PERMIT ISSUANCE T$[� � x
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �I
qa 2 1 hereby affirm that I am licensed underpmvisionofChaptel9(commencing with JOB DESCRIPTION
4D OO_ Sectima 7(110)of Division 3 more Business and Professions Code,and my license is in PANES
ftYU full fuse and effect. �/ a 1
JE Licenu CF ss Lic.N T UP TO 200AMP$ 1/
m W r; nam'��cnnwnnr IDI.1000 AMPS
F rA ARCHITECTS DECLARATION SQ.F1'.BOOR AREA 5/SQ.FT.
OO—3 OVER 1000 AMPS
OZj❑ rstwd my plans shell be usedupublic mcoms. M O
q�a4 W SIGNS ELECTRICAL
LicemeA 1'rofensional
"•� OWNER-BUIIAERDEhe Conn ., SPECIAL CIRCUIT/MISC.
50 V I hereby allirm tel l nm BUIL from to DECLARATION
or'e License Lew far the `7
W 3 q w
following lesson.(Section 7031.5,Business and Profession Coda.Any airy of County TEMP.METER OR POLE INST.
F F! which requires a permit to construct,aheq improve,demolish,or repair any ssructuu
WYE prior to is issuance,ulsorequirca the applicant for such permit to rite a signed statement POWER DEVICES
E E<0 that he is licensW pursuant to to Provisions of he Commerce.License Low,(Chapter
+rs•,%off 9(commencing with Section 70007 of Div" Businusend Rofession Cale) SWIMMING POOL ELECTRIC IIA�� VALUATION �/
W_rn or that he ixexemPt tercfrpm uis fur to elleg exemption.Myviolationof OIITLEfS-SWITCHES-Fl%TURES n �� r��l
F—Za Section 7031.5 LS bya want fora permit mbjauthe pplicennoacivil pcnelry mf L �\;J
SFO not more a undrtJ dolhn(5500).
Ce ❑ 0wnerofthe properry,army<mployeuwitwag utheirulecompensation, NEW 0.LSIDEN1LM.F.LECI'R _SQ.PI'. STORIES TYPE CONSTRUCTION
y322 wil athe work.and the structure is not intended proffered rsale(Sec.7W.Busineas
and rufessions Code:The Conwaors License Law Joe not apply m an owner mf
pro y who builds orimprovesthercon,and whodossuch orkhimselfortmughhie OCC.GROUP RES.UNITS
h wtpinyas,pmviJeJ tmuch improvemenuarc not into edmefferedforsnle.ff,
q the buildingor improvement is sold within one year ompletion,the owner-
huildet ill btrve the edf ora he diJ nal builJo improve far purpose of
Intold. QT'Y, PLUMBING PERMIT FEE I'hOOD LONE APN
❑ Lu ownerof lusrvely n+mrncting with icenud contractors to
nmswn the 1stness and Profession C cp The Conaar'e PERMIT ISSUANCE ense1wolpropertobuilds ori vestercon,andraw etaforsuN glicensed Pursuut ate Conwemr's ALTER-DRAIN&VENT-WATER(HA) FEE SUMMARY
License 1.w
❑ I um xcmpt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY TY D ES N
Owner Data RF.CEIP`#
DRAINS-FLOOR,ROOF.AREA,GOND.
W MAN COMPENSATION DECLARATION SCHOOL TA% YN_
❑ Ihercb em thatlhave acertificn¢of conunno ul0insure,aecertifceu of RECEITTa
Fl%TURGS-PER TRAP
Workers an,loyer innlerdbi, or a.I,, iOeA copy thereof(gee.3800.Lab CJ which PARK FEE Y N
010oven all emPlnya's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS BUILDING DIVISION RECEIPT N
Policy# ON EiEs
Company GAS-BA.SYSTEM-OVER 4(HA) PIANCHECK PER \
S ❑ Cenifial copy is hereby furnishuf.
❑ CcnifieA copy is filed wit the city inspection Jivieinn. GRIASPIINDUSU�W TBTR°D'�P6mf? TOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ;6R1SA ES'RAP- L SOILS FEE �P
COMPENSATION INSURANCE
(TLissenion aced nm be completed lithe permit is(r.,
Bo trite(5100) SEWER-S ARY 5 EA.400E(', ENERGY FRE
or less.) sas
I certify tat in the performance mfthe work for whiissu 1 1 AT RW CTR knm employ any person in nay trumer see u m taco PAID
t Cmnpcnutionl,awsof Califnmia. Dau E S T• I G "PavelReceipt 41
0 ,Z Applicant
Z 0 NOTICHID APPLICANT:If.after meting this Cerifmnu of Exemptio o sl old W ?SII PLMB. SQ1 l TOTAL:
.> becnmeauompythe Workers Colons or this pmvisinn)he deenborC must
6rhwit comply with such Provisions or this pcmtiuhell be deemed revoked. AA� BUIL PFE
CONSTRUCDON LENDING ADENSEISMI
,`,`,`,`,`,`444444{{{{{{'��y��y''' Dn .ypglS.•)#t" C PI?I?
� 'z Iherebyuffirm thrurmem.c.meme,on lendingagen rte�pcoance of y,...
0 the work for which this Permit is issued(Sat.3097,Civ.CJ l ELF.CIRIC P ai
Lender's Name "IT'S
C" Lenders Address aa.✓' QTY. MECHANICAL PERMIT' FEE PLUMBING 'E
0 U I ccrify that 1 have road this application and state that to above information is \�
cortect,lugree to amply with all city and county ordinances and than,laws rcletingmPGRMIT ISSUANCE MECHANICAL E
buildingeonsuuction,and hereby authorise repreumenivw oftis city toenter upon the CONSTRUCTION AN
U Z above-mentioned property foe inspection purposes. ALTER OR ADD TO MECH.
(We)agreeto save,indemnify and kap harmless ore City of Cupertino again
liabilities.judg ems,costs and expenses which ma enywnyucifgai tsaid "ty AIRHANDLING UNIT(TO 10,000 CFM)
in tsZepum f the granting oftis permit. 1
AIR HANDLING UNIT(OVER 10.000CPM)
.ignmurcnf Appficam/Cmnnaamr Gulf EXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE ((EATING UNIT(TO IW,000 BTID Date Receipt
Will the applicant or future building occupant stare or handle blues daus material
u defined by the Cupctino Municipal Cale,Chapter 9.12,and the health and Safety BEATING UNIT(OVER 10(1,000 BTU) ATAL:
QNe,Section25572(a)7
0Yes 11 No VENTILATION PAN(SINGLE RESID)
AlmOWill theappli'strumfnture buildingeoeupaat useequipmentordevicas whichernit
BOILER-COMPUHPORIW,O(I(1BTIH ISSUAN ATE
Dn arp:s air comvnimants res defined by the Day Area Air Quality Managemem BO UM-COMP(OVER 1100,01M)BTU)
isui 17 k.4
❑Yes ❑No NI?W RI'SIDENTIAL MECH. SQ.FT.
1 have awl the hacmdous materials rcyu ramems under Chapter 6.95 of the
I und �E�
Culilbrnie I Icullb&Safety Code,Sections 25505.2550 and 25534. erstand tat 7y
if the bullJiug Anew not cunen0y have a arra,or:n it in my rcsponibility to notify the /�
^
Ornpnttlot Ibe rcyuiremems which most be met prior to issuance of a Cenificate of f#
ccupancy.
Owner rnuutnriud agent Dau SSUP.D BY
OFFICE