27447 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EIA UI HTCAI. PERMIEND.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJF:T IDENTIFICATION 27447
BUILDING )D S9: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT
OWNER. N a PIIONI?: COM'RACI'OR'S NAME: LIC NO:
NIC C(1NTROLp
RCIIITIEC N.E LIC NO: ADDRESS: ❑
:ONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDINGPEIiMITINFO
-
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 0 X ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
o z iZ: I hereby affirm Etat l am licensed under provisionsol Camera(commencing with
QOW Liuenoc Cme, of ySan 3 S�eL Business and Professions; a dmYlicenu is in PANELS 1
4: 30JC—i//� UPTO2WAMPS 1\_Y•`..JAI '
y=y [)at, _– Contractor 201-W00AMP$ S T-T FLUOR AREA / E/SQ .FT.
ZOyZ ARCHITECTS DECLARATLON Q OVER 1000 AMPS
OZ_n I understand my plans shill M used as public mends.
r y t w SIGNS ELECTRICAL
Q 44 7 j Licensed Professional
edW< OWN17RBUILDER DECLARATION SPECIAL CIRCUIUMISC.
�N�iz aU n 1 hereby affinthat 1 um exempt from the Contractor's License Law for the 1+134vFi following reaun.(Section 7031.5,Business and Professions Code:Any city 0r county TEMP.METER OR POLE
F�0; which requires a Permit a construct,altar,improve,demolish,or repair my mucturc
prior to its issuance,also requires the applicant for such Permit o file a signal slatemem POWER DEVICES
that he is licensed pursumuo the provisions of the Contractor's License Law(Chapter SWIMMING L ELECTRIC
9(commencing wish Section710(kJof Division 3 miles Businessund Professions Ceded VALUATION
or that he is exempuhortfrom and the basis for the alleged exemption.Any violation of
FZQ m
Section 7031.5 by yapplicant Im.p.it subjects lheapuo
plicana civil penally of OUTLETS-SWITCHES-FIXTURES
FSDnl comethun five hundred dollars S50T.
mt. ❑ 6asnwncrnfthcpropeny,ormyemployms with wagesaslheirsolecomp ossm.a.. NEW NESIDF.NTIALCLECTR _SQ.FT. STORIES TYPE CONSTRUCTION
a3. willdethe work mdtbe awaurc isnot intended confined!fmsale(Site 9004.Business
and Pndeasiuns Gme:'Ihe Contractors I ivi,me Law does not apply to an ow.tt of
properly whnbuildsurimproves thermgandwhod.essuchwofk himseforthrough his
nemployces,providedtbat such improvementsmenol inlerah,imnffemd forsale.If, OCC.GROUP RIS.UNITS
however.the building or improvement is sold within one year ofcompletion,the owner- TO L:
builder will have the burden of proving that he did not build m improve fm purpose of
sale.). FEE
❑ I,m ownerot the propeny,n xclusively contracting with licensedcomroatmam QTY. PLUMBING PERMIT F, D'/.ONIi APN
construct the projat(Sec.4044,Business and Professions Ceded The Conuacmr's PERMIT ISSUANCE
Liccnulawdeasnotapplymanownerof property whnbuilJsmimproves therenn.md
who conlnctsforsuch projects with a camrachide licensed pursuant to the Comaelors ALTER-DRAIN&VENT-WATE (EA
License Law. ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C fnT this reason O TIDE
BACK FLOW PROTECT.DF.VI h
SANI'f YN
Owner DateRECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF.A :A,COND. SCHOO.TAX Y
❑ Ihtteby uffimnhmlhaveacertificau of conummulf-insurt,maceniFiate of FIXTURES-PER TRAP RECEIP #
Wmkeri Compensation Insurance or acenified copy thereof(See.3800,Lab C)which PARK PIK, Y N
AIL RECEIPT#
ars all crp ee' onddr ��n F/ GAS-EA.SYSTEM-II C.40VTLES RIJI.DING DIVISION FEES
301myIt IIIT� 9
Company F I r GAS-EA.SYSTEMf VCR 4(IEA) I'IANCIF.CK ME,
❑ yC �.lied copy is hereby furnished.
Certified copy is filed with theciry inspection division. GREASE/INDUSTRL ASTE INTERCEPTOR G DINGFIEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP rs;xi, FEE
COMPENSATION INSURANCE
(This section need not 6ecompletd ifthe permit is for one hundred dollars(SIW) SEWER-SANITARY-S RM EA.200EFT. P ERGY FEE
or hexa.)
I certify that in the performance oldie work for which this permit is issued.)shillWATER HEATER W/VENT/EL
anh
not employ y person in any m se as la become subject to the Workers' AID
Compensation Unsaid Culifomia. Dau WATER SYSTEM/IREATING IKIUa T Receipt#
zZ Applicant
NOTICE TO APPLICANT:If,nice making this Certificate or Exemption,you should NEW RESIDENTIAL PL MB. SQ.FT. 'TOTAL:
V] becomexubject to the Workers Cnmpensadon provisions of the labor Code.you must
forthwith comply with such provisions or this pestall be md redeevoked. BU
rmit ILDING P'E
OW.. [� CONSTRUCTION LENDING AGENCY - °ISMIC PP.
Vz I hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097.Civ.C.)
tondos Name
fY. MECHANICAL PERMIT FEE PLUMBING FEE
O U LenJ;h Address Q'
C1 1 certify Net I have read this application and scare than the stove information rmminn is MECHANICAL FEF.
>"' Lk1 correct. lagfcmmon,comply
and herh all ebya city and county
ssitudndncesandmau lawsramin,act
upon gm PERMIT ISSUANCE
blove-gronnmaiomand hercbyanetodve purposes.
uvuof thiscirymenler upon the
(� z above-mcmiond pmPcrty for inspection puryoses. ALTER OR ADD TO MECH.
GDN$T'NDGTIGN TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabi lilies,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,00T CFM)
to wnsquence of the glomi.,of this permit.
AIR HANDLING UNIT(OVER IU,000 CPM)
Signature of Applicam/Contmcur Dau EXHAUST HOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO IW, Date Receipt#
Will Ou applicam or future building occupant store or handle hmmJous material
ac refined by the Cupertino Municipal Cade.Chapter 9.12,and the[health me Safely HEATING UNIT(O ble'noI BTU) 1,
Cock.Section 25532(a)'! VENJULAI'15K-AN(SINGLE RFSID)
❑Yes ❑ No
BOILEN OMPCHPOR 100,00013TU) ISS A E�DA4E /
Will theepplieamnrfmurc building wcupam use equipment nrdevices wM1ictemil Y
�bvallous air contaminants as defined by the Bay Area Air Quality Management BOI R-COMP(OVER 100.IXp BTU)
Distinct? 13 yes 6 MAY 41995
NIEW RESIDENTIAL MECH. SQ.FT.
1 have mad the ha>ardous materials requirements under Chapter 6.95 of the C�fYUf uy
Celifomia lleahh&Safmy Crile.Sediom 255115,25533 mJ 25534. l undersea d than �V rtt l l
i[die tuilding docsmlcurwtl avicet hot it is my repmm
sslbilitynotify the
occupant of the rc menu ich m 1 b< floe In issum<e of d Cenificat of
O cu
Owner r aul aria; m� Dau TOTAL: ISSUED BY:
OFFICS-