27746 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I:BING MECHANICAL MEC°FR ICA PERMITNO.
APPLICATION/PERMIT PLUMBING�hIECHANHIAI. 27746
BUILDING DIVISION � NUILUING I'Rl1JEC'I'IURN'I'IFICA'1'ION
BUILDING A/DDRPSS: SANITARY NO. 71CATION SUBMHTAI.DATE
69 saf
D/G#1 •r UNIT# LOT# aOWNERS ME: PNONE: CO NAM LIC NO: � ai
.� 4o8_d93-/93 c 9e f�u� 47S N/G COMROLa
TAR II :CNGI R: LIC NO: ADDRESS: ❑
(} exaEr[-eJ MEtroan
CONTACT: PHONE: QTY. ELECTRIC PERMIT FFF BUILDING PERMIT INFO
AD` 2-11-11JI BLDG ELECT1: PLUMB MECII
(' 7 o J.l — PERMIT ISSUANCE El El
LICENSED RACIOR'S DECLARATION APPLIANCES-RESIDENTIAL.
py,L Ihereby affirm that l am licensed under provisioneofampter9(commencing with TOB DESCRIVRON
P100 Section]IXXB of Division 3 ofll Btedresaund Pmfessiom Corel my license is in PANELS
fiollforce:,mlcltet 4n-P46
,,Zed Liccnsc Class -z0 G Lic.# UPT021XIAMPS
or6d Dam It-IL-14 Cnmractor�r SP:✓•�P-t- 201-IOIp AMPS
F y4 ARCI II fECS DECLARATION OVER IIXXI AMPS SQ.PF.FLOOR AREA E/SQ.IT.
0-ti.0 I undemudd my plans shall Iw used as public records.
F y F W SIGNS CLECTRICAL
EjLicensed l'rofessamill
yxQ OWNER-BUILDER DECLARATION SPECIAL.CIRCUIT/MISC.
OiU 1 hcrcby from that I am exempt form the Gmtmeters Llinsa Lnw far the
W 3 W h following reason.(Section 7031.5.Business and Professions Cale:Any city or county TEMP.METER OR POLE INS r.
1�-40a which requires a permit to construct.alter,improve,demolish,or repair any swcwre
�QYF prior to is issuance,also requires theopplicunt for such permitto file a signed statement POWER DEVICES
C< that he is licensed pursuant to the provisions of the Contractor's License Low(Chapter
i k Q SWIMMING POOL f;LECTRIC VALUATION
9(commencing with Section]000)of Division J of1M1e 9usirrcss and Professions Code)
q,•2' or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-Fl%TURES
t-Z,a Sect Lon?031.5 by any applicant for a Permit subjects the applicant w u civi l penalty of
�_❑ NEWRESIDENT1ALELECIR _SQ.FT. STORIES TYPE CONST RUCTION
O1
CFS nmore then five hundred Infirm,(5500).
❑ asE, ownerofthepropeny.ormyemployeeswiNwagesastheirsolecompensation,
will Jo the work,and the structure is not intended oroffcred forWe(Sm.7044,Business
and Proressinns Code:'fhe Commerce,hlceme Law Joos not apply to an owner of
property who builds or improves themush and who does such work himself or through his
cmpinyecn,provided Nm such improvemcntsart ort imm�dedoroffcredformle.IL OCC.GROUP RFS.UNITS
however.the building or improvement is sold within one year ofeampletien,the owner- AAL:
bu iol will havetheburdenofproving Ihm hedid nm buildurimprove fapurposeof
sale')'
[:] Lmowncruf the propcny.amcnclucontractingy contracting with licenscdcmrectoam QTY. PLUMBING T FEE IIAOD ZONE APN
construct the pmjccr(Sec.WALL Business and Professions Coda:)The Comracmr's
License Law does not apply to an ownerofpropcny thobuidoor improves thereon.and I'ERMII'1SSU
AEaJL
whocounrachiforsuch prejectswimacontmemr(s)li¢rsudpursuam mthe Contranmes VR-DRAIN&VENT-WATER Hist) FEE SUMMARY
License Law.
❑ I um cxcmPt under Sec. .B&P C r This reasonUTSIDE FEES
BACKFLOW PRO]'I;Cf.D ICE SANITARY YN
Owner Dao ORAINS�ROOR .GONDRECEIPT'#
, .
WORKMAN COMPENSATION DECLARATION SCIIGOLTAX Y N
r❑ I hereby affirm that l have ucertilicme ofcomsenrtheel6lnsurc,or kmra ficme of PINTO . E '1' RECEIPT#
WorkersCompensation Insurance or u catifal copy therenol 38M bC.)which PARK FEE Y N
covers all employees under this permit. G - A.S STEM-IINC.LIOUTLETS REC
Policy p BUILDING DIVISION SION PEES
Company AS-BA.SYSTEM-OVER 4 USA) PLANCUE CK FTE
❑ Certified copy is hereby furnished. in
71
❑ Cenifial copy is fled with the city inspection division. REASEal USIRL A CF. OR GRADING FEE
CER'I'IIBCATI:OF EXEMPTION FROM WORKERS' GREA ili 1' P SOILS FEE
COMPENSATION INSURANCE
This section need not be completed ifthe permit is future hundred doll (SEW) SEWER
_:SANITARYENPRGYIEE
Icertify that in the performance mso kforwhichthispermiss
itisu ,Ishall WATER HEA
ml so /HLECTR
not employ any person in my manner so as to account,subject to the orkere PAID
Compensation Lowsof Califrma. Date WATER .M/otFATING Dam Receipt Ji
ZZ Applicant
O NOTICE;TO APPLICANT:If.after making this Certificate of Exem 1Q Y.oshould EW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F' OL
hecnmt,subject to the Wmkcr's Compensation p.,isionsofthe Labor Cale,y BUILDING FEE
> forthwith comply with such provisions or this permit shall be deemed revoked.
aQ CONSTRUCTION LENDING AGENCY SEISMIC FHH
2 I hereby affirm that hem is a instruction lending agency forth permnmance of TOTAL: ELECTRIC RE
V O the work for which this Fenmil is issued(Sm.3097,Civ.CJ
Lenders Name PLUMBING ME
Q
0 F Lenders Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have mud this application and stem that the above information is MECHANICAL FEE
>1 F14 uomeet. I agree it)comply with all city and county ordiamecs trod state laws mladng m PERMI'l'ISSUANCE, /�+
UO building construction,and hereby authorize representatives of this city to enter upon rhe CONSTRUCTION TAX
V Z above-memimnd pmpeny for inspection pugroaes. ALTER OR ADD TO MECII.
(Wt,)agree m nave,indemnify and keep harmless Ne City of Cupertino against
Iiahiliues,luJgt nw,costs and expenses who against said City AIR HANDLING UNIT(TO 10,00 CFM)
in/con3que' to Bun p AIR HANDLING UNIT(OVER 10.100 CFM)
lL TC( J
Signature of ApplicanVConm Dam li%HAUS'1'IIOOD(W/DU0G PAID
DAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,IX10 BTU) Dale Receipt#
Will We applicant at future building occupant store or handle hazardous material
as derided bylhe Capenion Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1011,11110 BTU) TOTAL:
Cale,Section 25532001
❑Yes a VENTILATION PAN(SINGLE RFSID) u
Asd
BOILER-COMP CHP OR 100,(NIO BTU) 1jE/�59�1AdCF DATE
Will lair concantorfmure building by due Bay equipmentQualit Management y d z( 19,9 a ,
huz'rdi1 s air imaminanu as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 1W.0011 BTU) r IJ-sY'Qr
rte' ❑Yes ❑No NEW RESIDENTIAL MECII. SQ.111'. CII UI• L UrC„IIry'1
I have read the hazmdous materials mquimmt,nm under Chapter 6.95 of the V
Califnmis Health&Safety Calc.Sections 25505,25533 and 25534. I understand that
if the building does not cumemdy have a It,nenL that it is my responsibility to notify the
cupml of ere rcyuimments which must ere ma prim to issuance of n Ccnificate of _
Occupancy.
OwneroraulhorimJagent ,' Date 'I' Ar� ISSUED BY:
OFFICE