27031 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO - HUIUDINU-bLNCTRJCA. PERMIT NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL. 27031
3
BUILDING PROJECT IDENTIFICAq'ION
BUILDING fD ISS: 12:4s SANITARY NO. APPLICATION SUBMITTAL DATE
((//yy�J//N///�_7 N LOT N
OW A i PHONE: C R'S NAME: 1 CN
N/C CONTROL.#
• ARCM iCf/I:NGI ;B LIC NO:^ A ❑
ca CIt PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
Q ' 1 E PLUMB M1fEC 1
GUF/i /KIY PERMIT ISSUANCE El
'N SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL pB DESCRI ON
W'Me4z 00 I hereby uffinn that Lon licensed under provisionsofChapmr9(commencing with /�
W'00 Scctie hereby of Dl " 3nfce Businessa r Professions Coale,)(cmylicense with ppryP.LS
Lew
aVF full l'nrce:uW elf t/ UP TO 200 AMPS II I/ �
V nn —�..,d
� Affli Iv
<zw Llcemn Class Lic.N
why Doc Cnmmcmr201-1000 AMPS S F7.FLOOR AREA $/SQ,FI.
F'nnZ ARCIUTF.CT'SDEOVER 1000 AMPS Q
Z Orn I undcrstand my dices" all be medit
OZ—r)
SIGNS ELECTRICAL
Licensed Pndesaiunal
d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC.
XOatJ 1 hereby uffinn that I am exempt from the Contactors License Lew for the
m 3 a ao following mason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F LL O¢ which rertquires a permit to construct,elledufiles signed
improve,demolish,m repair any structure
'WYM prior its issuance,alsorequires me applicant for such pcmo filesigned shipment POWER DEVICES
�KQp shut he is liccnxd pursuannothc provision of the Convnctols Littme law(Chapter SWIMMING POOL ELECTRIC aaoX 9(commencing with Section 7")ofDivisim 3 ofthe Business and Pmfeasion.Code) . 'VALUATION
=rn or shut he isexempnhcrtfrom and the basis forth,ailegcd exemption.Any violationof marOUTLETS-SWITCHESFlXTIIRES
FZQ Section 7031.5bymyeppit.,fee.panni,subjeetstheapplicant m a civil penalty of -
5Ht< not e than rise hundred&It.($50o). NEW ftFSIDFNT1AL FlECIR SQ.FT. STORIES TYPE CONS'DiUCI'ION
CFa J3I.mownerofthepropcny.ormyemploymswiNwagua iMiraolecompensadm,
a3=° will do the work,and the structure Hart immrtdedorefferW forsale(Sec.]014,Business
and Pndessions Cede:The Commemr's License Law docs not apply no an owner of
property whobuildsor improvesthcrcon,andwhodces such workhimselfurthroughhis
1 Jed that such improvements t' termad mrofcoad fmrsde.If, OCC.GROUP RIS.ON]IS
employees. provemensarcnom
builder will
the have
the
burden of proving
is sold within one year or improve on,for the owner- TOTAL:
huedcr will have the hurJcn of proving chat he did not build or improve for purpose of
sale.).
❑ Idnsnwnenntbe property,amemlusivdyconvaningwith licensed amtmcnres to QTY. PLUMBING PERMIT PF,F. FLOOD ZONE AI'N
msuvct the project(Sec.9044.Business and Professions Code:) Me Contractor's
Li,row Law does not apply loan ownerol'property who builds or improves thereon,and PERMIT ISSUANCE
whocamtmet0orsuch projccrswintncontmeto0s)bcensedpumuanlmthc Conwnora ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ OUTSIDE FEES
BACK FLOW PROTEC.
DEVICE SANITARY Y N
Owner Date RECEIPTp
• co DRAINS-FLOOR,ROOF,AREA,CONU.
WORKMAN COMPENSATION DECLARATION SCIi00LTAX YN
❑ IheComperrm thntlhuveacenificamofcopythersif(Sm.391or aceni.))wmof FlXTIIRES-PFR TRAP RECLIPTp
Workers'Cnmpensatinnl mmnw oracenifiedc py hhcrmf(Sa.3800,Lab C.)which PARK FEE YN
rs all employee's rNl�re�is 1��J r7\ GAS-RA.SYSTEM-I INC.4OUTLETS RDIVISIa
Policy BUILDING DIVISION FEES
Company GAS-G.SYSTEM OVER 4 HLA) PLANCHFCK ME
❑ CpnitiWcupy bi ere yl ixhW.
C el copy is fled with the city inspwu d' ion. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATEOFEXEMPII FROMWORKERS' GRFASFTRAP SOILS FEE
COMPENSATIO SURANCE
(This nation need not be couplet thepcnnitisfcumulundreald Han($100) SEWER-SANITARY-STORM FA.201017, ENERGY FEE
or less.)
I certify that in the once of the work for which this Permit is i ued.I shall WATER HLATER W/VENT/ELECfR
man in any m er so as to become subject tut t te Workers" PAID
Z (:mpensutinn Laws of Califomt Date WATER SYSIEMITREATING Date ReceiptN
A liwm
z 0 Nc 'ICH'1'O A PLICANT n t is Cenificati, E ptiun you should NEW RESIDENTIAL PLMIL SQ.FT. 'TOTAL:
o
H .�. beer rteIi f esu pensation provtsmns nr I Cr ,you must
LnM lha c Inovuimn on ' bulk y`JY� BUILDING FEE
(.� CONS IpN AG SEISMIC FEE
Ih b al am thatch traction lend' agencyfor the rfmmance of
U O y TOTAL: ELECTRIC FEE
I
work m which this pc t s a seed(Sec. ,Civ.CJ
Lender's as
III
TY, MECHANICAL PERMIT FEE PLUMBING FEE
O U IsnJIc Idris Q
1 can y that I have ma s city
and county
and sum Net an above information is / MECHANICAL FEE
>" correct.Iak c ith all city and county ordinances and stmelaws relating to PERMIT ISSUANCE
buildingeons .and emby authorise mpmmnumses of this city to enter upon the
V Z above-mention dpnpen mi exam.purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)ug c m a ve n mnify and keep harmless she Cityof alp no agaims
isthilities.pal nems, r t an expenseswhichnuymanyway accrue gain. avid C' AIR HANDLING UNIT(TO 10.00di
iremoc'um e fdi in f i mnit �ell, -�
AIR HANDLING UNIT(OVER 10.(X10 CFM)
Signomm of AaXemaCorance, r Date EXHAUST HOOD(W/DUC7) PAID
I IA%ARDOUS MATERIALS DISCLOSURE HEAPING UNIT(TO 100.000 BTU) Date ReceiptN
Will the applicant or future building occupant store or handle harurdnua material
as cannot by the Cupertino Municipal Crile,Chapter 9.12,and the I lotHEATING UNIT(OVER Ifp,O(X19TUJh and Safety TOTAL:
Cur,Section 25532(n)P VENTILATION FAN(SINGLE RPSID)
❑Yes ❑Nox,
Will the applicant orfumrcbuildingoccupantesuequipment serdevices which emit
BOILER-COMP(3HP OR IIXI,OgI BTU) / k—ISSSIANC�DATE
•
hazaNmm air emarromares us refined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District, 1:1 Yes 25 1995
Yea No NEW RESIDENTIAL MECH. SQ.Ff.
1 have read the In fou.materials tequireme r.under Chapter 6.95 of the CII Y UI' t,urtn I INC)Califnmiu Hath&S.CCIY CWc,Smuons 25505,25533.d 25534.1 undastrad that
if the building docs not currently have a mvn.that it is my responsibility to notify the
occupant of the requirement which must M met prim to issuance of a Certificate of
Occupancy. It
OwneroromhoriecJ agent Date TOTAL: T ISSUF,D BY:
OFFICE