27938 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - h1..C1'NI AL PERMID NO.
APPLICATION/PERMIT PLUXIBIN'f: . F.CHANICAL 27938
BUILDING DIVISION U :C'1'IDENTIFICATION
BUILDINGADDRES�://f / T SANITARY NO, APPLICA'DON SUBMITTAL
�DA'I
OI W�UNITp LOTp
OWNIiRSNAME: 1 'HONE w� CONTRACTOR'SNA LIC NO:
1 lxC COMAOL#
ARCIII'TEC/ENGINEER: IC NO: ADDRISS: ❑
'ONTACI': PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECF PLUMB MECH
PERMIT ISSUANCE /4n ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDII FIAL
neez I hereby affirm that l am licensed underpmvisionsof Chapmr9(commencingwith 'C )N
000F Section 7")of Division 3 adore Business and Professions Code,and my license is in PANELS mak_
��t fall form and cffm. UPTO200AMPS
Liccu,e Class Lic.N
�n?y Date Gnomic ert 201-1000 AMPS 6Q.t9'.FLOOR AREA E/SQ.F-1'.
ZOv z' ARCtIITEGTS DIiCLARATION OVER IOW AMPS
O Z—M I undemard my plans shall be used as public reco ds.
SIGNS ELECTRICAL
Licensed Professional
�yits 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOy V I hereby affirm tom I am exempt from the Contractors License taw for the
W3t-r following reams(Section](131.5,Business and Professions Code:Any city car county TEMP.METER OR TOLE INST.
fS°; wldel,reynires a praraa to m,mmmt,ager,improve.demolish,or repair any stmmnm
prior m its issuance.also requires the applicam for such penoi to file a signed st<tement POWER DEVICES
cd K G that he is licensed pursuant to the provisions of the Contractor's License law(Chapter
ie., CSWIMMING POOL ELECTRIC VALUATION
xe 9(commencing with Section]000)of Dlvision3ofine Businessand Professions Code)
W_co 'that he is exempt hnstmm and the basis for the alleged exemption.Anyviolatimnmf OUTLETS-SWITCHF,S-EI%TURES
,r_Za Section 7031.5 by any applicant far a prouit subjects the applicant to a civil penalty of
no mote than five hundred dollars($5W).
W!= NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
aCFS ❑ othe wrk,anhcestrucY�ormyempendedoroferegeassthered (Sm.competxsiiess
3O° willdnmewons andth'Hae Coeisnrus License Law
eoesntapply to an Business
and Rmfessmm'Cmle:'ITe Cnmmcmrx License Low drxa not apply m an owner of
pn,pcny wmb.ild.,tar improves thcrenn,and wh.timssuch work himself or thro lthl6s
employees,Providedthat such impmrt
mveemsanot imendedor offeredfarsale.If. OCC GROUP RLS.UNITS
however,the building or improvement is sold within one yemofecmplction.the owner. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,asownerofthepropeny.umexdusivelyconimctingwithll¢nxedcomracmmm
commit the project(Sm.70144,Business and Professions Code:)The Contractor's
License Lawdoes not spplyto an ownerofpropcny whobuildsmimpmvesthercen.and PERMIT ISSUANCE
wIn contracts for such projects with amnarac„bs)licensed pr'uantm the Contractor's
Liccmc Law. ALTER BEA) FEE SUMMARY
❑ 1 am exempt under Scc. .B&P C fm this reams BACK FLOW PROTECT.DEVICE QDTSIOI'FEES
Owner Date SANITARY Y N
BRAINS-FLUOR.ROOF,AREA.COND. RRCEIPT p
'illsWORKMAN COMPENSATION OF SCHOOLTAX Y N
❑ Thereby affirm that Ihaveucertificatc a come th self-i Adoracem beatIt IgXTURES-PERTRAP R6CF.IPTN
coven 9Cmployeeanler this oraccni(cd ropyth f(Scc.3RW.Lab C.)w 'h PARK FEE Y N
covin all employee under this pctmiLGAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'p
Policy p BUILDING DIVISION ILLS
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHF.CK FRE
❑ Cenifiesimpyisherebytumished.
❑ Ccnificd copy is filed with the city inspeni ivisinn PNERMID
USTRL WASTE INTERCT;PTOR GRADING FEE
CFiRTIFlCATE OVEMn
FROM WORKERS' P SOILS FEE
COMPURANCE
(nissectionneednotbecomitisfortare andreadd ars($HxhITARY-SI'ORMEA.2WFT. ENERGY FEE
or less.)
(certify that in the pertormfor which,his permit is issu all F:R WNENT/ELECfR
not emPloY any person in anyo bes'nme subjcn the c. PAID
Z Compensationlaws ofCnlilmminGM/TRIiA'1'ING411FTE
Date Receipt#
Applic tNK s
Z 0 NOTICE TO APPLICANT:If after making this Cenificaroof Exem mush Id NTIAL PLMB. TOTAL:
G oecmnesubject the Worse .Compensation provisions ofine La e,yo ut
7 I hw hh comply with such p ov$mans or Thi,permh shall he dee dr ked. BUILDING FEE,
W t SEISMIC FEL
Q CONST UCfION LENDING AGFAY J
Iberehyaffirm,hattherei acmmwctionleadingag rNe pc of
U O _ ELF,CfRIC FF.E
I--� tbaorkforwhich this permit is ued(Sec.3W],Civ.CJCL. 1"' Lenders Name PLUMBING hliliLeads,,Address QTY. MECUANICAL PER
U L certify that 1 have read this apph tion and state that the above information is MIiC11ANICAL htiE
correct. l agree tocomply withal[city and my ordinances and state laws reIn rillto PERMIT ISSUANCE
I-" n' hnilding utmnuminn,and hereby authnrire rcpr. nmtivcsoRhis city mm�mr uponthe
fA CONS'MUCT10N TAX
U Z Aswe-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless t ity of Cupertino agains
Imbilitie 'uJgmen¢,crosp soden may in dray way eagains,said 'y AIR HANDLING UbE r(To IOA00 CFF,)
in max •dthegt1rol,
(_v
AIR HANDLING UNIT(OVER IO,fgq CFM)
Signa, canuctucturtmV Date EXHAUST HOOD(WNUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO HA"BTU) Date Receiptp
Will the applicant or froom building mcupant.store or handle hasnrdous material BEATING UNII'(OVER 100,000 BTU) TOTAL:
as definM by the Cupertino Municipal Code.Chapter 9.L2,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RISID)
❑Yes ❑ No
ISSUANCE DATE
Will theapplicumorfutumbuildingcncupamuseequipmenmrdeviceswhichemit BOILER-COMP(3HP OR 100,090 BTU)
za dous air contaminants m defined by Be Bay Arca Air Quality Maaegemam BOILER-COMP(OVER UK."BTU)
District?
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.IT. e
1 have read the ho mous materials requirements uirees ander Chapter 6.95 of the ARR 141
CAfnmia Health h Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building t not curremly have a tenant,th it is my owponsibilq ui nwify the
ecru+ mcnt,whic�met be uanc`of v Cenificare of CITY ur I t,rk
fkcupancy.
Owner or am Dam TOTAL: ISSUED BY:
OFFICE