27951 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fIR:D2NrreITUMI' PERMITNO.
APPLICATION/PERMIT PLUMBING,-MECHANICAL. 27951 7 A C 4
BUILDING DIVISION I �}(� BUIIL`DINNG.PROJECT IDEN'TIF'ICATION 1 J J 1
BUILDING ADDRESS �ni l�su �0. bbd# • R` SANITARY NO. J:A!PPLI��ONSUBMITTALDXIIli
1 [� Q[(�y 0 L01.
N/C CONTROL#
•ARCHITF.CI'/ENGINEF.R: LIC NO. e^1 + F (X ( T4
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MF;C11
PERMIT ISSUANCE ❑ ❑ 1� El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RBSIDENTIAL
Oatz I hereby affirm that l am licensed ander,revisions ufChepter9(commrncingwiN JOB DESCRIPTION
P O0 Section 70001o111'visi..3 of the B....s,and Profession Code and my license is in PANELS
m full fmcc and of)
FyyUj Liccnu Class-L!L�L�LLiup �`�� UP TO 2W AMPS
'<e. Dm Commcmr� OVER
-IOW AMPS
F 4 ARCIIITE91;DECLAR n` SQ.FT.FLUOR AREA !117.
1 undron nd my plans shall be used as public records. OVER 10110 AMPS
OOPE21N_-w SIGNS ELECTRICAL
6 E,', Liciumed Professional
a:n. N
OWER-BUILDER D17CLARA'HUN SPECIALCIRCUIT/MISC.
yU 1 hereby affirm that I am exempt from the Convector's License Law for the
m3ay following mason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE B45T.
b-E C a which requires a Permit to consvum,al¢q improve,demolish,or repair any structure
prim to its issuance,also requires the applicant for such Perrot to file a signedsmtement POWER DEVICES
K 0O that he is IicensJ pursuant to the provisions of the Cuneacmr's License Law(Chapter,
soars[ 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
w=v4i
or hciwxempuM1ercfrom and the basis for the alleged exem
nption.Any violefon of
tKa Section 703 L5 bymy applicam farapamait subjects the applicant t tyof
OfpfLEl'S-SWITCHES-FlXTURES
not mote than five hundred dollars(SSW).
K m ❑ I,avownernfohepmperty.nrmyonpLycuwiN eau s,hru mlacma,maatio NEW RESIDENTIAL ELECIIt _SQ.FT. STORIES TYPE CONSTRUCTION
L willdothc work,andthestrunumis not intendedor.ff forsale(See.9044,Busittcs
and Probessiuns Cods:*Me Cmuracml w does not apply m an owner of
property wh.builJxorim .vest erenn.und whnJcessuch war Im.wefonhmughhis
OCC CROUP RES.UNITS
.wncmployecs,Pmvide hat such improvcnrcmsare not intend offcredforsale.If,
bo"i'vur,Nebuilding ort pnorme lissoldwahm, etion.the owner- TOTAL:
builder will have the hurt n of proving that he did no b i t C.
a for pu u of
'she.), QT PLUMBING PERMIT FEE FLIR)D ZONE npN
La, he Protea IS 0,14.B sine velyc uai ns lice^ Ras
canstmct the,a,rat(S .a. r.f a d ions Cgtle) mr's
Liccnu Luw docs nal uppl o sea rofss .buildsQQQr�ttl)P p PERMIT ISSUANCE
whnconvac¢f.rsuchpmj swith I rts tic sed pu \fah" Convac r ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License taw. LL
TE
❑ 1 um exempt under Su. Ns& C for Thi BACK FLOW PROCT.DEVICE 11T51 fE1S
SANITARY YN
OwnerData DRAINS FLOOR.ROOF,AREA.GOND. RECEIPrp
WORKMAN CO 1PIiN5 FION DECLARATION - SCHOOL.TAX Y N
❑ IbertbyaMv
ffiern eac ifeme.fconwmmself-insure, ecerfificnteof RXTURIS-PER TRAP RECEIPr#
WnRern Compensation Insurance. O ornifieJ copy thereof(Sec.3 g,WhCJ which PARK FEE Y-N
-
covers all employee s under this RECEIPT#
Pc^n GAS-tq.SYSTEM- INCA OUTLIiTS RU ILDI NG DIVISION FEES
Policy p
CompanyGAS-F.A.SYSTEM-OVER 4(EA) PLANCIIECK FIiE
CICenifted copy is hereby the
El Certified copy is filed withth the city
inspection division. GREASIYINDUSTRL WASTE INTERCEPTOR GRADING FLG
CERTIFICATE OF EXEMPTION FROM WORKERS' GO 'TRAP SOILS FEE
COMPENSATION INSURANCE
Oltisucti.n neat natbe completed i(Ne permit isfor.ne hundred dalars($I W) SCW - ANI'TARY-STORM EA.200P- ENERGY FEE
or less.)
I certify that in the performance of the work for which this pemtit is issued,I shut[
WA IEATSR WNENTpiLECTR
m
not employ arty person in any manner so u to became subpart to Be Worked PAID
Compensation Lawsof Celifomm. Date WATER SYSTEMfOUATING Dam Receipt#
ZZ Applicant
O NOTICE TO APPLICANT,If,after making this Cenificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
I-' ry become subject u the Workers Compensation provisions of the LaMar Code,you must
� > forthwith comply with such provision m this From,shall be decmW revoked. BUILDING FEE
1 [� CONSTRUCTION LEiNDING AGENCY SEISMIC FEE
Z I hereby affirm Nat then is a construction lending agency for the performance of T 12LEMIC FEE
U O thework for which this permit is issued(Seu.3099,Civ.CJ
I<ndeh Name PLUMBING ITE
U' F Lender's Address QTY. MECHANICAL PERMIT PGE
V 1 certify that 1 have read this application and sone that the above information is MSCI IANICA 1.FEE ss
>- LL7 enrtect.l agree to comply with all city and county ordinatres and glom laws renting to PERMIT ISSUANCE
F' 0" buildingconsrruction,and hereby authorize representatives ofthis city mercer span Ne CONSTRUCTION TAX
Vz above-mentioned pmpmy for inspection purposes. ALTER OR ADD TO MFCH.
(We)agate t.save,indemnify and kap harmless the City of Cupmin.against
ilitic it ms,nrsos and cxpensn which may many way accrue against said City AIR HANDLING UNIT CFO 10,000 CFM)
in cost u n of the ran of Nis permit ,Q( AIR HANDLING UNIT(OVER IO,"CFM)
SignIbirs,.IApplican 'o tmcon 'DA?
D EXHAUST HOOD(W/DUCT) PAID
11AZARDOUS MATERIALS DI LO RE HEATING UNIT(To IW,WO BTU) Date Receipt#
Willthe applicant or future building occupant st handle hvardous maeried HEATING UNIT(OVER IW,000BIM)
as refined by the Cupertino Municipal Code,Chapter 4.12,and the Hcalth and Snety TOTAL:
Code,Section 2 532(a)I VENTILATION FAN(SING
h6 RESOD)
ElYes ❑ No
ISSUANCE DATE
Will themplicmturfuwmbuildingmcupsnt useequipmeramdevices whichemil BOILER-COMP(311P OR IW,m)BTU) Try• p O D hamrdnus air conmmisants as defined by the Bay Are.Air Qm1ioy Management BOILER-COMP(OVER 11X1.000 BTU) 1� Pi
District? 9 0 (]
❑Yes ❑N. NEW RESIDENTIAL MECII. My IT. APR 1 V QQ
1 have read the hazardous materials requirements under Chaper 6.95 of the ls7si�
Celionnia Health&Safety Code.Suctions 25505,25533 and 25594. 1 understand that On
ifcapatodingdoesnmanceas yhave venemhmli rmy nuance of tymnotifythe ser curt
ccupant.f the requirements which must M met prior to issuance oft Certificate of
Occupancy. _ Y
Owner or authnm4d agent Dam TOTAL: ISSUED BY: