27794 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO B .LD1\ r-hLhU.R1 AL PERMITNO.
APPLICATION/PERMIT
PLUMB.NT:-MECHANICAL n 7 7 9
BUILDING DIVISION BUILDING PROJEC'1'IUEN 1'IRICATGION I 4
BUILDING ADDRESS: G SANITARY NO. APPLICATION SUBMITTAL DATE-
0;,
ATE
Odi Oso,_ A)ov ry�/,,c_o ,/1. UNIT It LOT# 111 J
OWN IiNSN ME: PHONE: CONTRACTOR'SNA# LIC NO:
N/C CONI KUL#
•ARCIII ICT/FNGINEER: LIC NO: ADDRESS: tea• ❑
CONTACT: PHONE: BUILDING PERMIT'INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT P{,I1M0 MECII
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL '#r�
G1"L I hereby offimuhat l am licensed un&rpmvisionsof Chepter9(commeneingwitM1 1 TOB DIi R$[ Ha''ION
FL00 Section 7001 Division 3ofdre Business and Professions Code,and my license is in PANELS
U(1
WF. full force and effect.
UP 10 2(X1 AMPS
F%til License Class Carr
m 6 u Dale ConTS D 201-❑X1U AMPS
F h! ARCIIIlECTS DECLARATION SQ.1°f.FLOOR AREA S/SU.FT.
GOtn Iunderstand mypbossball heusedas public recorde OVER ItXlO AMPS
O'L—❑
r 4 F; SIGNS ELECTRICAL
LicenneJ Professional
�yd'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOy V I hereby affirm that I sum exempt from the Conumctora License law for the
t+)3la. following reason.(Section 9031.5.Business and Professions Core:Any city or county TEMP.METER OR POLE INST.
TSO¢ which requires a Fxrmit m construct,alter,improve,demnllsh,or repair any strum..
tuux11YJ prior toils issuance,also requires the applicant for such pemtitto file a signedsmmmem POWER DEVICES
p�j N¢p that he is licensed pursuant to the provisions of the Canntrnnor's License Law(Chapter
0 SWIMMING POOL ELECTRIC
dao 9(cnmmencing with Section]000)of Division 3 ofthe Business and Professions Cade) VALUATION
.m—m or that he is exempt herefrom and the basis for the alleged exemption.Any violation of I � -
5.KQ Section 9031.5 by any applicant for a permit subjects the applicant to a civil penaltyof OVTLFi I'S-SWITCIIF,S-FIXTURES
Mn nod more than five hundred Jolters(SSW). NEW RESIDENTIAL ELEC.R SQ.PT.
9Fo ❑ Lacownerofthepropeny,nrmyempluyeeswitM1 wagesmthcirsolecompensation. STORIES TYPECONSTRUCTION
a3:L will do me work,and the stmnum is not intended oroffered farcale(Sce.9044,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property whobulldxor i inprovc therutm,and whodoessucb work himselfor through hos
employees,prnvidedlhatsucbimpmvemcntnamnolintendedorofferedforule.If, OCC.GROUP RES.UNITS
however,the buildingor inamovetrxnl is sold within one year of completlnn.the owner. TOI
buil&r will have the burden of proving that he did not build or improve for purpose of
stele')' QTY. PLUMBING PERMIT FEE, FLOOD ZONE APN
❑ Lasownendtbepmprty,nmexdusivelycnnlraciingwilh licensed commemrsm
instruct the project(Sec.70144,Business end Professions Col The C—unwmr's \
License law doesnot apply manownerofpropertywho buildsm improves thereon,and PERMIT ISSUANC12
whornntmets for such projects with ucontmewr(s)licensed pursuant to the Contractor's
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ I um exempt under Sec. ,B&P C for his reason OUTSIDE FEES
BACK MOW PKO'TECr.DEVICE
SANITARY YN
Owner Dam DRAINS-FLOORROOF, COND. RECEIPT
. , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX V N
❑ Iherebystirm that l have u camific.mnfer,con mself in..re.m.certificate of FIXTURES-PER TRAPREC.?I PI'a
Workeri Compemmiom
n lnsumnecor a cifed copy thereof(See3803.Lab C.)which ZP PARK FEE Y N
ell employees under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RLCHIPI#
Policyn# BUILDING DIVISION FEES
Company GAS-EA SYSTEM-OVER 4(EAI PLANCHECK FEE
❑ Crodieleq+y is hereby furnished.
❑ Certified copy is filed wimme city inspection division. GREASIVINDUSIRL WASTE INTERCEPTOR GRADING IT-E
CERTIFICATE OF 17XEMMON FROM WORKERS' GREASE TRAP SOILS FRE
COMPENSATION INSURANCE
(Ibis section necdnot be com,I,lcl ifthe penult is forone hundred dollars(S IW) SEWER-SANITARY-STORM EA.200FT. ANERGY FEE
or less.)
I certify that in the performance of the work for which this Permit is issued,I shall WATER HEATER W/VENT/ELECTR
not employ-any Person in any m as to become subject to the Workers' PAID
Cun+penxmionl.awsof Califomia. Date so WA'rBRSYSTENLTREATING Date Receipt#
Q Z Applicant
z0 NOT ICE TO APPLICANT:if.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ FT. TOTAL:
become subject o the Worker's Compensation Provisions of the Labor Code,you must
p > forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE Cl
13 CONSTRUCTION LENDING AGENCY SEISMICIEE
Dz
I hereby affirm that there is o conswnion lending agency for the perfommna of
U O ELF.CfRIC FEF,
the work fur which this Permit is issued(Sec.J09].Civ.C.)
Cts Lenders Name PLUMBING 17LE
P C) Lender's oddness QTY. MECHANICAL PERMIT I•T:E
V 1 certify that I have read IN,application mod stateThat the above information is MECHANICAL FEE
commit.l agree mcomply with all city anal county imbricates and state laws relating to PERMIT ISSUANCE
.k" 0 buildingeonstruction..ndbereby uuthorice representatives of this city tomar,upon the CONSTRUCTION TAX
U eb ve-ommomed property far inspection puryoses. ALTER OR ADD TO MECI I.
(We).gree n+sive.indetvndy and keep hunnlus the City of Cupertino against
liabilities.judgments,rainsvmexpenses which may in any way same against said City AIR HANDLING UNIT(TO M."CFM)
m coaxial fIIn Sof this pcmtit.
i � 2�1 1 AIR HANDLING UNIT(OVER I0,0(IO CFM)
Siynaturc of'ppli,m Cmmcmr J `sal, Date -XI LAOST Door(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000)BTU) Date Receipts
Will the applicant or future building occupant store or handle humorous material ABATING UNIT(OVER 100,001)BTU) TOTAL:
as defined by the Cupertims Municipal Cale,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)1 VENTILATION PAN(SINGLE REMD)
❑Yes ❑No
ISSUANCE DATE -
Willtheapplicaro urfutumbrildingecap.m useequipmetn ordevices whichemit BOILER-COMP(3HP OR I10.000 BTU) r#�
M1,'runlous air onn mirmus as defined by do,Buy Are,Air Quality Management BOILER.COMP(OVER 100,000 BTU) '
District? e_
❑Yes C3 No NEW RESIDENTIAL MECH.—SQ.Ff. RAR I]
13
1 have rend the hamrdous materials remiremem,under Chapter 6.95 of the I'I(S 1995
Cmil'omia l denhh&Safety Calc.Sections 255115,25533 and 25534. I understand that
it he building does nod currently have a tenant,that it is my responsibility to notify Ne y
enr
rcapant of the immiemems which must be met prim to issuance of a Cenificam of
Occupancy.
Owner or authoriumd agent Date T( ISSUE
OFFICE