27652APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOx
ILDING-ELLC'I RI AL
PERMITNO.
APPLICATION/PERMIT
PLUMBING - MECHANICAL
27652
BUILDING DIVISION
BIIILDIW: PNOJNC'1'IUEN'fl4'ICA'1'ION
BUILDING ADDRESS: /D 00, It_
Q 1/�
VjrI f,
SANITARY NO.
7��TIONSUBMIITTTAALDATE
UNI1'p LOI'M
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OWNERS NAME: PHONE: j
CONTRACTOR'S NAME: LIC NO:
16
N/C
CONTROL N
❑
RCIII'ItiCI'/IiNGINlili LIC NO. ADDRESS
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CONTACT: j PHONE: Qg
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Q'I'Y. ELF.CTRICPERMIT
FEC
BUILDING PERMIT INFO
BCUG CLiC'1PLUMB MECIaz
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Llm)
PERMITISSUANCE-
11 El 1:1
L_ICSED CONTRACTOR'S DECLARATION
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
hereby affirm that l an licensed underprovisions of Chapter9(commencingwith
Section 7") of Division 3 of the Business and Professions Code, and my license is in
PANELSNil
rx� r ��
(1/
l/ Na h
Lirevrecandeffttt.
eClaus 1
UPT0200AMP5
15
•I ��( ��/ Q_1P„C Lief
Dam Conn, $��
Dole Conn
1I AMPS
-R
ARCHITECTS DECLARATION r
OVE201
OVER IOOOAMPSSQ.
FI'. FLOOR AREA
E/SQ.IT.
1 undeatund my plans shall be used as public records.
SIGNS I:I,ECTR L
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL. CI U
1 hereby...affirm(Se that 1 an exempt from Contractor's License taw for the
Professions Co de: Any city orwumy
! Pr
TEM .MFfERO {'O IN9'T.
whowingeusoa(Seml inIInstrut, alar, sial repair any structure
which requires a permit m construct, alter, improve, demolish,
fi satemem
censedursunt tprvisioanUorwchperminoLicese
PoWIiR DEVICES
thtrtois
La
thatheis licensedpursuantthepmvisiomof the Commnm's LicenselawnsCo(Chapter
to th
VALAA'11ON
9lemnmenein6 with 5 jinn 9(KKll of Division 9nf the Business and Professions Cale) SWIMMING POOL ELECTRIC
or he is exempt herefrom and the basis for the alleged exem 'on. Any violation of
Section 9031.5 by any arm
pplicant for a permit objects the applic civil pengAkf
OUTLETS - SWITCHES -FIXTURES'
intone than five hundred dollars ($51p). •_�
n❑ I.asownernftheprt)Pny,ormyemployeeswithwmges t t.olecom4'q(��p�^ci1�
NEW RESIDENTIAL ELECfIt S .FT.
Q
STORIES
TYPE, CONSTRUCI ION
will do the work, and the structure Isnot intended oroffeed for sa ee. 9044, BSiness
and Professions Cade: The Contractor's License Law d apply m vAa, of
property who buildsar improveetheeon,andwhodons kM1imx this
OCC. GROUP
RES. UNITS
umpl,m, providedthaLwchi mpevemcnlx mean 'etc dedmi, df sale. If,
however, the building or improvement is wld within n cdom,12on,I eowner-
TOTAL:
builder will have the burden of graving that he dt Imi rit�rotf for put"ac of
F11c)' \
QTY. PLUMBING PERMIT
FEF,
FLOODZONE
APN
❑ I,asuwneroflheprti eny,atnexclusivelye cti hlicensedconaaaorslo
ct the project (S. ]0ki. Business and Profession. ode:) 'The Contractor's
construct ec
-
Licenselawdoesnolapplytoanownerofpmpeny who buildsorimpmvesthercon.and
PERMIT ISSUANCE
who contracts her such pmjeas with acontmctorho licensed pursuant to Contractor's
Limn Law.
gLTF.R -DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ 1 an exempt under Sec. . B & P C for this reamn
OUI'SIDI: PEES
BACK FLOW PROTECT. DEVICE
SANITARY Y N
RECEI"4
0., Date
DRAINS - FLOOR. ROOF,ARFA. CON D.
SCHOOLTAX Y N
WORKMAN COM PENSATION DECLARATION
R IM1ercby affirm thaO have ucenificate of consent la xlf-insurt,macenificue of
FIXTURES - PERP
RECIi1P1'tt
PARK FEE Y N
umra mhificd copy thereof(See. 3800, Lab C.) which
Workers' Campanian. lmmcor
vers ellcmploya's un�Sr`1n'I lit.
GAS -FA. SYSTE NC. O S
RECIiTPI'k
BUILDING DIVISION FEES
Pnlicyp I.�-�I�yP S-- qi 'XPi �-4J-�
Company
GAS -E,A. SYSTIi B4 EA)
PLANCHECK FEE
"
fj1 CenifiN copy ¢ hereby famished. '
GRADING FEE
❑ CenifieA copy is fled wish the city inspection division. GR lDUSIR AS I RCEPfOR
CERTIFICATE OP EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FET:
COMPENSATION INSURANCE
ENERGY FEF.
(This section need not be completed iflhe permit is for one hundred dollars P$100) SEWER -SANITARY- STORM EA. 201114.
ar less.)
I mrifylhut in the perforrommof the work far which this permit is issued, Iaha11WATER HEATER W/VEN3'/ELECTR
not employ any person in any manner so a to become subject to the Workers
PAID
Compensation Lawsof Culifomia. IAIe
WATER SYSTEM/IREATING
Dam Remipta
Applicant
NOTICE TO APPLICANT: ILaRer makingthis Certifies. of Ewmdi...you should
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
become subject the Workers Compensation provisions of the Labor Code, you must
ttor
fonhv int comply with such provisions or this Permit shall be deemed revoked.
BUILDING FEE
SEISMIC ITH
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a consavetion lending agency for the perfomunce of
the work for which this Permit is issued (Sec. 307, Civ. C.)
TOTAL:
ELECTRIC FEE
Lcoders Name
Lender. Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify that 1 have read this application and state that the above information is
MECHANICAL FEE
,reel. I egree to comply with all city and county ordinances and state laws relating to
PFRMI'T ISSUANCE
to ilding construction, and hereby umborim reprnsntatives of this city locate, upon the
CONSTRUCTION TAX
abuse-mcmioncd propany for inspection purposes,
ALTER OR ADD TO MECH.
WO agree to save, indemnify and keep harmless the City of Cupertino against
liabilities.judgments,cossund reopens which may inany wayaceme against said City
AIR HANDLING UNIT(TO 10." FM)
In wn.sequaeofthe nonrigid this per it.
-f p
,� &1Q, ;Wes
AIR HANDLING UNIT( 10,1 PCF
PAID
Applic/Contractor auv' F) Date EXHAUST HOOD (WNU
Signature of ant
��
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100jil IB
Dam Receipt»
TOTAL:
Will the applicant or future building occupantstorc or handle hmardons..amil RfSkTINGU (OVER T U)
;is defined by the CuPenino Municipal Code, Chapter 9.12, and the Health and Safety
.ODO
Code, Section 25532(x)'1 VENTILATION FAN (SIN ,ERESID)
❑Yes ❑ No
TF
TUAM
BOILER-COMP(3HPOR 100,000BTU)
Will the applicant or future building occupant useequipment or devices which emit
urandous air contaminants as defined by We Bay Area Air Quality Management
BOILER - COMP(OVER 100,00013111)
Distinct?
13
❑ Yn ❑ No
NIiW RESIDIiN'1'IAL MECII. SQ. PI'.
231995
1 have read the hmardau.s materials requirements under Chapter 6.95 of the
, b /�
California Health &Safety Code. Sections 25505,25533 and 25534. 1 understand that
y�'��F Vi U&ILK�NV
if the building does not currently have a tenant, that it is my responsibility to notify the
f thremens u which must he met prim m issuance o Cmu t.te of
cupen, oe re ui
Occupancy, o �+
ISSUED BY:
Owner or authorized Pent Dam TOTAL P TOTAL:
OFFICE