27803 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUH•DATrti1:F,LTRICA[ PERMIT NO.
APPLICATION/PERMIT PLUMB INO-MECHANICAL 2 7 8 0 3
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L I O J
BUILDING ADDRESS: ^J^/ SANITARY NO. APPLICATION SUBMII11*11'�AL DATE
✓f/ LOT p LT�r�g
OWNS NAME: CONTRAMOR'SNAME: LIC NO: N/C CONTROL# V
W 7 fo 7
CHITI?CI'/iNGINEER: LIC NO: RESS: ID/ BON/TW
CONTACT: PHONE9 QTY pppy'(S h "1."ECfRIC PERMIT!3 t FEE: ; BUILDING PERMIT INFO
BLDG .LECP PLUMB MCCH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
C)WZ I hereby affirm that l am licensed under provisions ofaapter 9(commencing with ��. 101 DESCRIPI' _p.�
r�00 Section 7M)of Division J ofthe Business and Professions Code,and my liccme is in PANELS \`r\y✓.A�I� \/V
W'W� full fora and eff«t.
.Qr'!.W Livens Clms�/- Lic.p ��9 7_ZLcl UP TO 2o0AMPS
w Q�• Palo - Conoactad�r It.VN'Albs 201-1000 AMPS
FNh AR' ITECractor" RATION SQ.IT.FLOOR AREA $/SQ.IT.
p�'?O lux pP d. tdl mZATIO OVER ROD"I's
F aaF j / v SIGNSZigELECTRICAL
Qy � Lice d
�sy�Q ssm OWNER-BUILDER DECLARATION SPECIAL CIRMIT/MISC.
Z, .7F-;r,
I am,,nffinn that I and exempt from the Contmcmrx License law for to
W m followingrn.son.(Section 7031.5,Business uad Professions Cc:Any dry or county TAMP.METER OR POLE INST.
F 0Q which mqu fres a permit to construed,alter,improve,demolish,or repair my swcture
�'�Y5 prior m its issuance,also requires theapplicant far such permit to file a signed I....I LOWER DEVICES
csl W OQ0z tat he is licensed pursuant to the provisions of the Contracm
tola Lieee law(Chapter SWIMMING POOL ELECTRIC
cd aLL 9(commencing with Section DivisinnJof to Businessland Pmfesaimm Cale) VALUATION
yYj_y or Nat he is exempt therefrom and the basis foi alleged exemption.Any violationof
FZ. Section 703 1.5 by any applicant for a permit subjects the applicant asa civil penalty,of OUTLETS-SWITCHES-FIXTURES
Esq not morethan five hundreJJollarx($500). NEW RESIDENTIALELECfR _SQ.FT. STORIES TYPECONSTRUCfION
, 0 ❑ I,asownerofte MoWc y.ormyemployeeswitwagexaxthcifsolecompemation,
y3;L wi0dotcwork,andthesimcmmisnotmtendedorofferdfoTsele(Sm.]064,Business '
and Professions Code:The Contmmor's License Law docs not apply to an owner of
pmPcry whobuildsor im,moax thereon,and whmdaux such work himulfmmmim hhis
r I 'Jed that such improvements t intended or offered for sale.If, OCC.GROUP RES.UNITS
employees,the ha ding pis sold nhin neve enflic
however,eerwillhav l due
rien of
issoldhe ii noneyear or improve
Boon,purpar r-
TO
builder will have the burden of proving that he did not build or improve for puryox of
sola)' QTY: PLUMBING PERMIT .FEE
❑ Lax the project
ny,am eadmis and Proaaings Codc:)The omplactsdo ROOD LONE APN
License the project(Sec.]ado Business and Professions Crimp The Ceorda,and
License Lewd«rstuh plyuI with arofpropeny whnsedpuarimproves Contrcond PfiRMI'1'ISSUANCE
whense Law.lbrsuch projects with acontmnor(x)licensed pursuant the Controanr's ALTER DRAIN PA
License Law. (� I PEE SUMMARY
❑ I am exempt under Sec. .B&P C for this won OUTSIDE FEES
BACK ROW PROTECT.DEVICE
SANITARY Y N
Owner Dae RECEIPT
WOR KMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,COND, SCHOOLTAX Y N
❑ IhercM1y nflinn thntlhuvcacertificme of amunua sdf-insurt.arncertilicatc of FIXI'UR17S-PER TRAP RF,CIiIPI'p
Workers Compensation Insurance or a certified copy temof(Sm.3901 Lab C.)which PARK FEE Y N
Pall employees under his .it. GAS-EA.SYSTEM.I INC. OUTLETS RECEII'1'a
olicyrs It BUILDING DIVISION MES
Company - GAS-EA.SYSTEM.OVER 4(EA) PLANCIIECK ME
❑ Cenificd<upy is hereby furnished.
❑ Ccnilied copy is filed with to city inspection division. GREASIVINDUSTRI.WASTE INTERCEPT OR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS TEE
COMPENSATION INSURANCE
(This s«tio,need not h completed ifthe permit is for ate hundrddollars(510) SEWER-SANITARY-STORM EA.20FT. ENERGY FEE
or less.)
I cenifytat cache Perfnrmenee of to work for which this .I,is issued,Isha11 WATER H FATER W/VIWT/ELECTR
ant employ any .on in any manner so uy m berm t.lp the WarIT �. - PAID
Compemaion laws _fn_rq��}yDate z�-I�e � 1` ATERSYSTEM/fREATING Doc R«cipt
Z APPhant
c . "If- •V1411V C.�5 �T _
ZO NOTICE,TO APPLICANT:If.afro making ti a Certificate Eaemptioo,y h NEWR' IDE ALPLMB. SQ.FT. TAL:
I--' q become subject the Worker's Compensation provisiomr1de
umus> foMwith comply wit suchprovisions or this permit(sshalit BUILDING FEE
CONSTRUCTION LENDING AG ( / SEISMIC FEE
Uz Ihcrtbyaffirm thauhcrc ira<onswcuon lendingaaf TOTAL: ELF.CfRIC
O the work for which tis permit is bu ual(S«.309],Civ.C.)
Lender's Name
u' F Lender's Address QTY. MECHANICAL PERMIT FEE PLV I
U I certify that 1 have road this application and some that the above information is MEC ,hili
correct. I agree to comply with all city and county ordinances and state laws relating to PERMITISSUANCE
huildingcnnswction,and hereby andaunw representatives ofthis city toenter upon the
CONSTRUCTION T %
U Z above-mentionol property for inspection purposes. ALTERORADDTOMECH.
(We)agree in save,indemnify and keep harmless the City of Cupertino agaical
t liabilities judgmars,costs and meals
swM1i y way acegaimaid City AIR HANDLING UNIT(TO IO,O0(i
ons
'\ inceyuer.cAthe f his L
AIR HANDLING IJNI'f(OVF,R 10,001CFM)
Signe / Date EXHAUST ROOD(W/DUC) PAID ' J
HA RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10.0110BN)
Data Reccipl#
Will eapplies 'futom building occupant store or handle hazardous material
ax defined by the Cupertino Municipal Cde.Chapter 9.12,and the health and Safety 111?A'1'ING UNIT(OVER 100,010(c)BTU) TDI'Ah:
Code,Section 25532(x)1
❑Yes 13 No VENTILATION PAN(SINGLE RPSID)
ISSUING ATG
\ WilUM1enpplicantnrfroombuilding«<upamuseequipmemordevices whichemit BOILER-COMP(JHPOR 10,00 BN)
haranlum air comamidams as defined by the Bay Area Air Quality Management - q
BOILER-COMP(OVER IO,UW B'fU) M
U.ncfl R
❑Yes ❑No NI:W RIiSIDENTIAL MECH. SQ.FT.
I have mad the hazaMous materials dequirtmcnu under Chapter 6.95 of the
Califomia Health&Safety Care,Sections 25505,25533 and 25534. 1 undersand that
ifthe building does not currcmly have atenam,that itis my responsibility to notify the / PIry
dormant of the requirements which avid la,met prior to issuance of a Certificate of rCM
Occupancy.
O
Owner or authorized agent .Date ISSUED BY: