27782 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO1MUnth;-LLEUJAfEri PURMITNO. 27782
APPLICATION/PERMIT PLUMBING-MKCHANICAL
BUILDING DIVISION BUILDING PROJECT]DEN'TIF'IC.A'1'[ON
BUILDING IGADDRESS: / SANITARY NO, APPLICATIONSUBMIITALDATE
{ ��1U �1 � ( NIT# LOTH 3 S-�fr
OVEISNAME: PIIONF: I CO TRACI'OR:SNAM& LIC O: fsC CONTROL#
G L 5-13
ARCIIITIi T/IiNGINF.tiR: LIC NO: A)DRESS: �, ❑
Sao .-1r �a
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
BLDG ELECTPLUMB MECH
PERMIT ISSUANCE ❑ ❑ a ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
c3wz Ihereby uffum that l am licensed tinder provisions ofaloner 9(commencing with
POR Section 7")of Division 3 ofthe Business and Professions Code,and my license is in PANELS
bedF<Z, full formClass feet.
u license Clens LiaN UP T0200 AMPS
m6y (late Choose 201-I"AMPS
ZOyZ ARCHITECTS DECLARATION SQ,FE FLOOR AREA S/SQ.F-1'.
CZ-0 1 understand my plans shut[be used m Public records. OVER IIXI(1 AMPS
r'4tW SIGNS ELECTRICAL
Licensed Professional
%'�< OWNER-BUILDFR DECLARATION SPECIALCIRCUIT/MISC.
Oa F- I hereby affirm that I am exempt from Ne Commences License Low for Ne
3 sr-ma following reason.(Section 7031.5.Business and limitations Code:My city or eaumy TEMP.METER OR POLE INST.
which repures a permit tat cmnswa,ocher,improve.dcmmish,or repair any sttunurc
prior to its issuance,also rescam the applicand for such Permit to file asigned statement POWER DEVICES
ty gip that he is licensed pursuanno the Provisions of the Convector's License Law(Chapter
aa9bumrancing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y Mvo or that he is exempt herefrom and the basis for the alleged exemption.Any violationof
Zs, Section 703 IS by any applicant for a permit subjects the applicant no a civil penalty of OUTLETS-SWITCMIM-Fl%TURES
tY onot more then five hundred Jnllas($SWI. NEWRESIDENTLALELECTR _SQ.F7E
❑ 1,atnwnerufthepropeny,ormyemployas withwogesmtheirnolecompensation, STORIES TYPECONSTRUMION
y3e2. will do the work,andlhenrulure is not intended or offered for sale(Sm.7044,Business
and Professions Cafe:The Convector's License Law does nut apply m an owner of
ownenywyces,pmvidedpnwesthimprovements oessuchwmkNmulfonhreogh his OCC.GROUP RFS.UNITS
ownempinyeex,provided that xuch improvememsare not imendedmroffercd Tarsale.If,
however,the bui[dinger improvement issold within one yearofcomptetio ilon owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
le.),
Cl Las(iwnerofthepmpeny,amexclusivelyconunctingwiNliceu cont tomto QTY. PLUMBING PERMIT FEE FLOODZONE APN
consume the project(Sec.7044,Business and Professions Code:)The Cm tours rs PERMIT ISSUANCE
License Law Joesnm applym mowncrofprapenywhobuildsm improves thereon,and ,Y
who contracts for such projects with a commeorfs)licensed personal o the Contractors ALTER-GRAIN&VENT- R. (G)
License law. FEE SUMMARY
❑ 1 am exempt under Sec. B&1'C for this reason BACK FLOW PROTE .DEVICE OUTSIDE FEES
SANITARY Y N
: Owner RDateAT RECF.IPf a
DRAINS-I•LOO OOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ .'Ccyaflir imat I firsum a inti. fifie conscmermf(ee.38 cattle C.)whicteofh
FIXTUR P.R TRAP RECEIPI'p
Workers Coployeationder thus ermit. ifetl copy thcrcof(Sec.3flW.Luh CJwhich PARK PER Y N
Police all nnployee'a under this permit. RECEIPT#
-
Policy p P.A.SYSTEM-1 INCA Ol1Tf.f?TS BUILDING DIVISION FEES
Company GAS-P.A.SYSTEM-OVER 4(I:A PLANCIIECK FEE
❑ Certified copy is hereby furnished.
❑ Cmified copy is idled with the city irepection Aivision. GRFASEANDUSTRL WAS IE :R i—x .I'L'O GRADING FEE
CERTIFICATE OF f:%F.MPI'ION FROMWORKER S.
GREASE TRAP IIS FF.E
COMPENSATION INSURANCE
(11k,celomecd not he campteted ifthe permit is to one hundreddollars(SIM) SEWER-SANITAR) MEA. ['NF. YFEE
or less.)
Icent fy that in the performance of the work for which this permit is imued.lahall WATER HFA /ELE �D
not employ wy person in any manner eco as m become subject -the Wdhers % ID
Z Compensation Lmesof Cnlifnna. Date ATERSYS pATI Date Receipt
Applicant
'ZZ 0 NOTICE TO APPLICANT:ILalter making this Cenifmam of Exemption.you should .W RESIDENTIAL B. SQ IT. TOTAL:1-" y become subject to the Workers Compensation provisions of the labor Code,you must
� ? forthwith comply with such provisions or permit shall he deemed revoked, BUILDINGFEE
z
CONSTRUCTIONthe.i. LENDING AGENCY
SEISMIC FEE
1 hereby affirm that rcrit is issued
thee. lending agency for Ne performance of TOTAL: ELECTRIC FEE
U O Te work for which this permit is issued(Sea 31q],Civ.CJ
��--++ Lender's Name '
Ll. l--' Lenders Address QTY. MECIIANIC PERMIT' FEE PLUMBING HE d
W1 certify that 1 have read this application wd atm that the shore infomntion is MECIIANICAI.FEE.
correct.lagrcemcamply with till city urd county ordinances and stele lawerelnningm PERMIT IS AN
building construction,and hereby auNorim rcpmsentmivm otlhis airy m enter upon... CONSTRUCTIONTAX
U above-maihonW property fur inspection purposes. ALTER OR ADD TO MECH.
(Wc)agree to save.indemnify and keep hornless,the City of Cupertino against
fail ex,ju mems,co nal expenses which may in my way accrue against mid City AIR HANDLING UNIT(TO 10,000 CFM) 7 .�
' is am r ti oflhisperent. AIR HANDLING UNIT(OVER 10.000 CFM) pp
Si nal eofApplicant Data EXHAUST HOOD(W/DUCI) PAID J_�C
H)aUS MATERIALS DISCLOSURE HEATING UNIT(TO INTOM BTU) Date ReceiplN ''/1
Will the applicant or future building creeper,store or handle hemrdom mineral HEATING UNIT(OVER 100,000 BTU) T'OTAL: ! QV
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2 532(a)] VENTILATION FAN(SINGLE RIISID)
❑Yes ❑No
BOILER-COMPOHPOR IMMOBTU) ISSUFFYYAhJCTA F
• Will doupp[icmmrfnurebuiMing occuPmt useequipmemordevices which emil j�
hmurdous it comannu ams as definW by the Bay Arca Air Quality Management
BOILER-COMP(OVER 100.000 BTU)
District]
❑Yea ❑No NEW RESIDENTIAL MECII. SQ.M. MAR 11995
t hove rend the hazardous materials requirements under Chapter 6.95 of Ne
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that CI IY Vr wrCly I IIVU
if the mi Idling does not curmw
emly have a el,that it is my responsibility he notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy,
Owner or unmerited agent Dam TOTAL: ISSUED BY.
OFFICE