27138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II 1 LUM;-ELKC I RICAL PERM]TNO.
APPLICATION/PERMIT PLUMBING -MECHANICAL 27138
BUILDING DIVISION BUILDING PROJECT IBRNTIFICATION
11LDINGG AADDDRms: SANITARY NO. APPLICATION SUBMITTAL DATE
I6V Si UNITN LOT is
NERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: Ue
N/C CONTROL N
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p(Z I hereby affirm that lam licensed underprovisionsof Chaptcr9(cmnmencingwitM1
Op Senion]000)of Division 3 ofthe Business and Professions Code,and my license is is PANELS
5t56
ZE fullforceandeffeet.
LI¢nm Class Lic.0 UPTO20JAMPS r�
y6y Dum Corona, r 201.1000AMPS
Z O,Z ARCHITECTS DECLARATION SQ.FT.FLUOR AREA Q.IT.
I understand lens shall be used as public records. OVER 1000 AMPS
OZ-0 YP Pu .c
QW SIGNS FLECI'RICAL
� Licensed Professional
e5 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. • ^ C\�.
4OaU 1 hereby affirm that)am exempt from the Contractors License Law for the 4 "{�
u
TEMP.METER OR POLE INST.
3Ovf—i I'nllowing rcusna(Sectinn]O3L5,flusiness and Pmfeaeiona Cade:Any city or county
SS�y n which requires a Permit in construct,alcor,improve,demolish,or repair my structure Q�\`,
2 >7 prior mini issuance,also"ifeca the applicant for such Fourth to file a signed statement POWER DEVICES \
Gpz that he is licensed pursuant the Provisions ofthe Corrector's License Law(Chapter -
a�j cW 9(commencing with$ecti.n]o(gl)of Diviaion3ofthe Businev and Profensi.naCWe) SWIMMING POOL.ELEC'T'RIC H VALUATION
or the,he is exemptnberefrom and Ne basis for the alleged excmp.....Any violet....of OUTLETS-SWITCHES-FIXTURE$
aSection]031.5 by my applicantfor a permit subjects the applicant to a civil penalty of
not more than five hundied dollen($51%)' NEW RISIDENTIAL ELGCfit _SQ.FT.
0 Cl I,mnwneroftheproperty,.rmyempl.yceawith wagesmtheinolecompensation, STORIES TYPE CONSTRUCTION
y�_ and Pothe wons C d e:The Coronations
oonatwrimm�dedm Law
do Pon t apply.t oan,owner of
and Professions Cale:The Conwetors license Lew does not apply m an owner of
property whobuildsorimproves thereon,and whodcessuchwork himselforthroughhis OCC.GROUP RFS.UNITS
awnempioyces,brivith dmat such improvet¢nHue not intndedoroffered forrole.If,
however,the building orimprovcment is sold within nue yearofecmpleion,the owner- - 1,
builder will have the burden of proving that he did urn build or improve for purimse of
side).
❑ 1.vowncrofthepmpeny,amexclusivelycontrsmingwithliccnredconmlomto QTY, PLUMBING PERMIT FEE Flt]OD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contracmrs PGRMI'T ISSUANCE
License Law does not apply to an ownerof property who builds or improves thereon,and
whoccntracts for such Projects with acuntrvcmr(s)limmutpunuannothe Connacmes se Law.
License
ALTF.R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,R&P C for this reasonID
BACK PLOW PROTECT.DEVICE
SANITARY YN
Owner Date RECEIYT4
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.GOND. SCHOOL TAX VN
❑ Iherchy nffrm thud have ecer[ifcate of concern mazlFinsure......tiliemoof RXI'ORES-PER TRAP RECEIPTM
W.Acri Compemation Insurance ora comficimpydocomf(See.3800,Lab C)which PARK FEE Y N_
ars on employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPT p
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
❑ Certified copy La hereby famished.
❑ CmifieJ copy is filed with the city inspection div:¢ion. GREASHnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASL'TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit isiorone landred dollam($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the pertormantt of Ne work for which this Permit is issned.I shall WATER HEATER W/VENTAn.LEC1R
not employ,any person in my manner so as to become subject to the Workers' PAID
1 Compensation Laws of California. Date WATER SYSTEMITREATING Dane Receipt Is
0 7-+ Applicant
Z 0 NOTICE TO APPLICANT:if oftermaking this Cerifirom of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F" V) boaxmesubjectto the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions aphis Permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a comnuu,ion lending agency for the performance of TOTAL: ELECTRIC FEE
U Q the work for which this Permit is issued(Sec.3097,Civ.C)
u. Lenders Name
0 Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING PRE
I certify that I have read,his application and state that the above information is
carrot.l agree to comply with all city and county ominancesandnam laws relining to PERMIT ISSUANCE MECHANICAL FEE
h buildingconstruction,and hereby authorize repreameaives oflhis city mentor upon the - CONSTRUCTION TAX
U above-memioned property for inspection purposes. ALTER OR ADD'1'O MECII
(We)agree to save,indemnify and keep hernamat the City of also no again
liabllitiox.judgmencs,cmts andexpensu wNch may many wayett 7h I OAIR HANDLING UNIT(TO ,WO CFM)
in consequence of the granting of this permit,
AIR HANDLING UNIT(OVER IO,IXO CPM)
rgnomre of Appli .mrvnm Dow F EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt
Will the applicant or future building occupant store or handle hazardous mmedal 1IP.ATING UNIT(OVER I IX1,100 pTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sector 25512(u)? Or
Cl Yes 13 No VENTILATION PAN(SIN(SINGLERESID)
)
Will theapplicarn BOILER-COMP(311POR IIO,
or future building occupant ueccyuipmeordevicee which emit WOBTUi,,a ISSUANCEDE
hazardous air conmminmts as defined by the Bay Area Air Quality Management !• i"
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. Oor O ��
1 have read the huardoua materials mluimments under Chapter 6.95 of the s
California Health&Safety CWe.Sections 25505,M533 and 25534.1 undcmtand than tl�y Ur a/7}
if the building does not currently have a mount,that it is my responsibility m notify the ��J� /
occupant of the"noterenta which must be met prior m issuance of a Certificate of a D'
Oci
Owneror
Owner rn authorized agar pre TOTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II 1 LUM;-ELKC I RICAL PERM]TNO.
APPLICATION/PERMIT PLUMBING -MECHANICAL 27138
BUILDING DIVISION BUILDING PROJECT IBRNTIFICATION
11LDINGG AADDDRms: SANITARY NO. APPLICATION SUBMITTAL DATE
I6V Si UNITN LOT is
NERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO: Ue
N/C CONTROL N
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p(Z I hereby affirm that lam licensed underprovisionsof Chaptcr9(cmnmencingwitM1
Op Senion]000)of Division 3 ofthe Business and Professions Code,and my license is is PANELS
5t56
ZE fullforceandeffeet.
LI¢nm Class Lic.0 UPTO20JAMPS r�
y6y Dum Corona, r 201.1000AMPS
Z O,Z ARCHITECTS DECLARATION SQ.FT.FLUOR AREA Q.IT.
I understand lens shall be used as public records. OVER 1000 AMPS
OZ-0 YP Pu .c
QW SIGNS FLECI'RICAL
� Licensed Professional
e5 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. • ^ C\�.
4OaU 1 hereby affirm that)am exempt from the Contractors License Law for the 4 "{�
u
TEMP.METER OR POLE INST.
3Ovf—i I'nllowing rcusna(Sectinn]O3L5,flusiness and Pmfeaeiona Cade:Any city or county
SS�y n which requires a Permit in construct,alcor,improve,demolish,or repair my structure Q�\`,
2 >7 prior mini issuance,also"ifeca the applicant for such Fourth to file a signed statement POWER DEVICES \
Gpz that he is licensed pursuant the Provisions ofthe Corrector's License Law(Chapter -
a�j cW 9(commencing with$ecti.n]o(gl)of Diviaion3ofthe Businev and Profensi.naCWe) SWIMMING POOL.ELEC'T'RIC H VALUATION
or the,he is exemptnberefrom and Ne basis for the alleged excmp.....Any violet....of OUTLETS-SWITCHES-FIXTURE$
aSection]031.5 by my applicantfor a permit subjects the applicant to a civil penalty of
not more than five hundied dollen($51%)' NEW RISIDENTIAL ELGCfit _SQ.FT.
0 Cl I,mnwneroftheproperty,.rmyempl.yceawith wagesmtheinolecompensation, STORIES TYPE CONSTRUCTION
y�_ and Pothe wons C d e:The Coronations
oonatwrimm�dedm Law
do Pon t apply.t oan,owner of
and Professions Cale:The Conwetors license Lew does not apply m an owner of
property whobuildsorimproves thereon,and whodcessuchwork himselforthroughhis OCC.GROUP RFS.UNITS
awnempioyces,brivith dmat such improvet¢nHue not intndedoroffered forrole.If,
however,the building orimprovcment is sold within nue yearofecmpleion,the owner- - 1,
builder will have the burden of proving that he did urn build or improve for purimse of
side).
❑ 1.vowncrofthepmpeny,amexclusivelycontrsmingwithliccnredconmlomto QTY, PLUMBING PERMIT FEE Flt]OD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contracmrs PGRMI'T ISSUANCE
License Law does not apply to an ownerof property who builds or improves thereon,and
whoccntracts for such Projects with acuntrvcmr(s)limmutpunuannothe Connacmes se Law.
License
ALTF.R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,R&P C for this reasonID
BACK PLOW PROTECT.DEVICE
SANITARY YN
Owner Date RECEIYT4
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.GOND. SCHOOL TAX VN
❑ Iherchy nffrm thud have ecer[ifcate of concern mazlFinsure......tiliemoof RXI'ORES-PER TRAP RECEIPTM
W.Acri Compemation Insurance ora comficimpydocomf(See.3800,Lab C)which PARK FEE Y N_
ars on employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLET'S RECEIPT p
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
❑ Certified copy La hereby famished.
❑ CmifieJ copy is filed with the city inspection div:¢ion. GREASHnNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASL'TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit isiorone landred dollam($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the pertormantt of Ne work for which this Permit is issned.I shall WATER HEATER W/VENTAn.LEC1R
not employ,any person in my manner so as to become subject to the Workers' PAID
1 Compensation Laws of California. Date WATER SYSTEMITREATING Dane Receipt Is
0 7-+ Applicant
Z 0 NOTICE TO APPLICANT:if oftermaking this Cerifirom of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F" V) boaxmesubjectto the Workers Compensation provisions of the Labor Code,you must
forthwith comply with such provisions aphis Permit shall be deemed revoked. BUILDING FEE
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a comnuu,ion lending agency for the performance of TOTAL: ELECTRIC FEE
U Q the work for which this Permit is issued(Sec.3097,Civ.C)
u. Lenders Name
0 Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING PRE
I certify that I have read,his application and state that the above information is
carrot.l agree to comply with all city and county ominancesandnam laws relining to PERMIT ISSUANCE MECHANICAL FEE
h buildingconstruction,and hereby authorize repreameaives oflhis city mentor upon the - CONSTRUCTION TAX
U above-memioned property for inspection purposes. ALTER OR ADD'1'O MECII
(We)agree to save,indemnify and keep hernamat the City of also no again
liabllitiox.judgmencs,cmts andexpensu wNch may many wayett 7h I OAIR HANDLING UNIT(TO ,WO CFM)
in consequence of the granting of this permit,
AIR HANDLING UNIT(OVER IO,IXO CPM)
rgnomre of Appli .mrvnm Dow F EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt
Will the applicant or future building occupant store or handle hazardous mmedal 1IP.ATING UNIT(OVER I IX1,100 pTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Sector 25512(u)? Or
Cl Yes 13 No VENTILATION PAN(SIN(SINGLERESID)
)
Will theapplicarn BOILER-COMP(311POR IIO,
or future building occupant ueccyuipmeordevicee which emit WOBTUi,,a ISSUANCEDE
hazardous air conmminmts as defined by the Bay Area Air Quality Management !• i"
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. Oor O ��
1 have read the huardoua materials mluimments under Chapter 6.95 of the s
California Health&Safety CWe.Sections 25505,M533 and 25534.1 undcmtand than tl�y Ur a/7}
if the building does not currently have a mount,that it is my responsibility m notify the ��J� /
occupant of the"noterenta which must be met prior m issuance of a Certificate of a D'
Oci
Owneror
Owner rn authorized agar pre TOTAL: ISSUED BY:
OFFICE