27779 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1.1INI:-R1b.1ARIC PERMIT No
27779
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLIGr^'1'''ION SUBMI PIAL 13A 11
AlRe� UNI3'a LOTN / J
OWN ) Ili: PHONE: / CONTRACTOR'S NAME: LIC NO:
0-i— � - - �3 G7 s(,� Njr: CONTROL«
ARC)IITI:CI ;NGINCCR: LIC NO 5 / d ADDRESS: ❑
M _..
CONTACT PHONE: - } + BUILDING PERMIT INFO
5763 7 QTY, q"t,w ELECTRIC PERMIT FEE
10 b9 't 1+48�3E ELECT PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
M=7 1 hembyaflionthm l vin liaawdmrdmprovisimr fCTupmr 9(comntenemis with TOB DESCRIPTION
P02 Section 0000)of Division 3 of the Business and Professions Cade,and my license is in pgNFIS
toll farce send effe p UP T0200AMPS
<]w License Class
Lic.p S a
rF„•[y Date Contractor 201-1000 AMPS
understand7ON
ARC]IITECT'S DECLARATION OVER 1000 AMPS SQ FT.FLOQRARFA E/SQ.FT.
I unJeand my plans shell be used u Publi<rmN
as.
OZ-0
1 O I,yy1/1
F y F W SIGNS EIECIRICAL `
Licensed]professional �V
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO W, I hereby affirm thin I vin exempt form the Convector's License Law for the
x13 a,,¢ following reason.(Section 7031.5,Business and professions Code:Any city or county TEMP,METER OR POLE INST.
I=I,O.J which refutes a permit m construct,alma,improve.demolish,or repair any sanctum
f WYS m,,at.ssuance,alsn he applicant for such Do Fle asi Wsu¢mmt POWER DEVICES
Ed requires pr permi gn
C¢ that he is licensed uant to the precision,of the Cane
nvtor's License law(Chapter
L4 Purs9 with Section p0lp or Division 3 of the Business and professions Code) SWIMMING POOL ELECTRIC VALUATION
(commencing wi ) )
t=m optionhat 7031.5 by tthcrtfmmand fthe buefin the asegWeaemptt to civiny l
of �BpS-SWITCHES-FIXTURES L Long
tZ2 Section 7031.5 by any applicant fmraPermit subjects the epplicnmmacivil penalty o! VL.(/
rZr� ntm an five hundred dollars($500). NEW RTI
ESIDENALELECDt S .PT.
KCp m ,asownernftuepropcny,mmyemployecswithwagesu Jmirsoleeompertsetion, —SQ.FT. I'YEE CONSTRUCTION
d3- will doth,work,and the structure is not intended mufrered frriWe(Sm.7041 Business
and Pmfcuions Coder.The Correctors License law does not apply to an owner of
pmpcnywhdbuildaooimpro'vei thertan,and whodoessuch work himulfrr Waugh xis
emplays,provided that such lmpowema
entsm not intendmr
edormorl brsale.If. OCC.GROUP RES.UNITS
hoeewever,the buildingor improvement is sold within tone yeanafcompletion.the owl L.
builder will have the burden of proving that h,did not build or improve for purlmse of
sale.). r s, \\ PLUMBING PERMIT FEEC] Luownerwfthe property,am exclusively contracting with limmedcoQTY.
oactorsto FLOOD ZONE APN
constructthe project(Sec.](134,Business and prorculanx Code)The Co orrO.'s PERMIT ISSUANCE
License law does not apply loan oxncrofpm,m,whobuildsbiimpmvesthermon.and
who contracts forsuch projects wit oinks s) '' edpurair the Contmetors
ALTER-DRAIN&VENT-WAIER(G) FETE SUMMARY
License Law. c
❑ 1 am exempt under Se .B&PSC for tlda rturn SIDE FEF'
r BACK FLOW PROTECT.DEVICE SANITARY V
Owner Dais 's RE-C—
Owner
1, DRAINS-FLOOR.Rt]OF.AREA,
t WORKMA MPI:NSATION UECLARATION,j SCHOOL TAX V
❑ Iheby n(fimtlhatlhes emificam O(cmnxnlmxlLinsafe,inn ani0cam of Fl%'ILRFS-PHR n RIiC1iIPTp
Workers'Compmation lnsuraaceor a moffied copy themof(Sa:3800,Lab C.)which // PARK HE YN
n all employee's urdenh,,permit. //yam .SYSTEh14 INC.4 OUTLETS RF,CF,IPf
policy ` J BUILDING DEVISE FEES
ComrI, 1 —1
P Y GAS-EA.SYSTEM-OVER4(EA) PhANCIIECK PEE
(j Certified copy is hcrtby(umisncd.
❑ CcnifiW copy is Bled with the city inspmuun Jivisian. GRFAEFJINDUSTRL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP ;Date
E
COMPENSATION INSURANCE
('Otis section need not be completed ifthe permit is forms,hundred dollars( 00) SEWER-SANT EA.2001-7 I'
or less.)
I certify that in the performance adds,work for which this permit is iseued,IsM1 I WAT 1 /VF,NT ,ELTR
not employ any pawn in my reamer se u to bjm}� Worse
Co.pcn.wtion f.pyyr(-(aIiNT� Da a-�T e SYSTE EATI ate Receipt p
Z Applicant ,red J 'Ii 0:(� nZ,l e�.ct_s C�
0 2 NOTICE TO APPLICANT:If,after making this Canificzm of Exemption,you sh�dd RESIU A PLMB. SQ.FT. 'f01'AL:
Wj) bccmmewbijecuotbe Worker's Compcneriimn previsions afthe Lubin CWe,you must G FF:E �.
a > forthwith comply with such provisions or this Permit shall lx thermal revoked.
LL) 0 HE
CONSTRUCTION LENDING AGENCY.
.7- z I hereby affirm Oat is a constrntim lending agency for the performance of C FEEU Othe work fur which this permit is issued(See.309],Civ.C.) \Lendera NameG Fli1iLenders Address Q MEC LAICALPERMIT FEEU 1 certify Nat I nave read this aMliestim and sum that the above information is
W atrmt.lugreemcomply with all city antcounry mrdiwnca andsum laws rtlmingm PERMIT IS ANCE I,� ICAL.PEErocine(upon the ON TAU zabove-mentioned property for inspection purposes. I.I'r RADD TO MEECH.(We)agree m cove,indemnify and keep hmmless the City M Cupertino against
AIR HANDLING UNIT(TO P),000 CPM)
quench o(theg gotthis permiti Dose reNnemlAIR fIANOLINC UNIT(OVER IO.000 CFM)
Signnoriiinee of ApplicanpCorrador Date/� EXHAUST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE �—�-y S HEATING UNIT(TO 100,000 RTU) Dam clip
Will the applicant or future building occupant store or handle hazardous material HEA'FINGUNIT(OVER 100,0X10 BTU) OTAI-:
as defined by the Cupertino MunicmpI CWe.Chapter 9.12.and the Health and Safety
Cade,Section 25532nd' / VF,N'FILATION FAN(SINGLE RJUAD)
❑Yes Lf
ISSUANCE DATE
Will lheapplicwmrlutumbuildingrucupant use equipment ordevlce.s whicheran BOILER-COME QHP OR 100.000 BEV) ^^ pp
limardous air contamntu rea
inas defined,by the Bay AAir Quality ManagementA
BOILER-COMP(OVER 100,000 BTU) P D
•DisvicR
❑Yes NEW RESIDENTIAL MLCH. SQ.FT.
I have read the foliations materials requirements under Chapter 6.95 of the MAR
AR 7 1995
California Health&Safety Cods.Section 25505.25533 and 25534.1 understarM Net
if the building docs not currently have a¢rant,that it is my mspmsibilay to notify the
xmpant of the rtwimmenLv inn most be timr amt Pm issuanceofream rf 11 Y � GUf-'tl
Own or autM1�md agent Dam L: ISSUED BY,
OF IC '