27669 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO MINI'.-HI.I?(.TRICA PERMITNO.
APPLICATION/PERMIT PLUMIIING-MECIIANICAI. 27669 7 6^9
I{UII,DINO DIVISION _ I UILDING PROJECT IDENTIFICATION G FV1 MV
BUILDING ADDRESS: �aJ SANITARY NO. APPLICATION
.S�UPMITI'AL DATE
A`030 �(' JI ��. ONI'1'M LOT# `mss/ F
OyyVli yNAM{;: PHONE: CONTgACf01fSN �: LIC�D
QV/• ` lrLs�V-1-_T (�a,c NIC CON'IR(Jl.tl
ARCIIITEC`OENGINHHR: LIC NO: ADDR S:' k _ ❑
CONTACIb PHONE: '
^ ( ^I �����/� QTY,
ELECTRIC PERMIT J•pH BUILDING PERMIT PLUMB U
/l?/ + N BLDG CLIiCf PLUMB MECH
PERMIT ISSUANCE ❑ ❑ Irtr ❑
LICENSED CONTRACTOR'S DECLARATION - APPLIANCES-RESIDENTIAL J�
p.z Ihreby
eaffirm that l am licensed underprovisions ofamacr9(wmmene.ingwith JOB DESCRIPTION
�00 Section Toot of Division 3 ofthe Business and Professions Cede,and my license is in
WdU full force and effect. PANELS
<Z, License Class Lic.If UPT0203AMPS IIX
c, Doc Contractor 201.1000AMPS Y l
ZOy�; ARC]{I'1 F:CTS DECLARATION OVER 10(10 AMPS SQ.FI.FL)Ok XREA $/SQ.M.
OZ-0 I understand my plans shall be used as public oemo s.
Fy~� Licensed PatientSIGNS ELECTRICAL
WQ OWNER-BUILDER DECLARATION SPECIAL CIRCUCOMISC.
ipS,O U I hereby offimt that I am exempt from the Contractor's License Low nor the
p+3 a w following reason.(Section 7031.5.Badness and Professions Code:Any city or county TEMP.METER OR POLE INST.
f��� which requires.permit m cimprove, m
amoraO,other.impve,demolish,or repository mcture
5.}� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W •CIO that he is licensed pursuant to the provisions of the Comandurs license Law(Chapter
Y ILo 9(mmwcndng with 5ecdon9000)of Dlvision3ol'Ne eusiness.nd Profeexlnns Code) SWIMMING POOL ELECTRIC
VALUATION
W=m mNat he is exempt herefrom and the basis for hmllaged exemption.Any ondmion mf
I_Z} Section 703 L5 by soy applicant for a permit suhjectsthemiticanno a civil penalty of OIITLEI'S-gWRCNPS-FIJCTURFS
Q not at than five hundred dollars($500).
q�O NEWRESIDENTIALELECB _SQ.FI'. STORIES TYPE CONS'IRUCTIO
❑ Lusownerof NcprnpertZO
ycmpinyeeswiNwj�w
ei , n>nt'on,
0.•�� willAn lbcwod,unJ nm mendeJ nroff elc(See.7044,Buanand Professions Calc:The Ctm'a License L Japply m an owner ofpmpcnywhabuilAsorimpmvon,andwhod euhideselforlhrnughhisown employees,pnrvidedthatpmvead a not d or.ffemd fnnale.If, OCC.GROUT' RES.11Nl'IS
m is sold wi in one rmpl tionJheownen 'fO fAl.:ing that h id not bicopm for purpose ofsale.).❑ I,suwnernfthepaperxdus' elycontranilic mmaorsm T PLUMBING PERMIT Ff:F: ILOODZONI? APN
onstruct the project(Sec.] usi and Profeste mrncm'License Law does not apply tone fproPetywhobHereon. nd 'RMIT' SSUANCE
ontracmr(s)ticensNOComraet rp vR DRAIN&VI?NT-WA"IHk LALicense Law. (' ) FEF.SUMMARY
❑ Iameamnu ndcrSec. &PCfm 1 ' SID.jqBIS
.OW PROTECT.DEVICE SANITARY Y_N
Owner Doe DRAINS-FLOOR,ROOF,AREA,COND. RECEIFI'A
• WOk AN COMPENSA O UF: LAR TIO SCHOOL TAX YN
❑ Ihcrcby affiml etlhavicemnific xm mselLin.ure,or nific of FlXTURfS-PER TRAP ctro'c1PIg
Worker.'Compenmt n lnsuranceorace o ydamad Sec.3800,LabC which PARK FEE Y N
coverall employee's der this permit. ! 27— GAS-EA.SYSTEM.I INC.4 OUTLETS RECEI I'Tof
Policy p BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK THE
❑ CcniGed copy is Must fumishe . It I
❑ Certified copy isfilcdw due city inspec on division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE FEXEMPTONFROM RKkRS' GREASE'I'RAP SOILS]FEE
COMP SATION INSO_ E
(Thissmfiorrommumbeen hocaliflhepe sforonehundecddoRara(SIM) SEWER-SANITARY-ST'ORM HA.20BFT. ENERGY II?E
or less)
I certify that in the Performance the r4 forwhich Niapermirisiss.ealidall WATER HHA'ITR W/VENT/ELECIR
_ not employ any Persian in any counter so ex to ccorm subject to the Workers PAID
Cmnpensmion Lawsof Califomie. Date WATER SYSTWITREATING Date Receiptp
0 z Applic.m
Z 0 NOTICE TO APPLICANT:If,after narking this Carificte of Exemption,you should NEW RP_SIDFAL]•LMB. SQ.ET. TOTAL:
F (q
became subject to the Workers Compensation provisions of the Labor Code,you must -
R ^ forthwith comply with aucb provisions minis permit shall be deemed revoke. BUILDING IEE
pW„ Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
.7- z I hereby affrco but there is a contraction lending agency for the performance of
V 0 the work Int which this permit is issued(Sec.3097,Civ.C.) 7 TOTAL: ELECTRIC FEE
(Y Lender's Name
0 Lender's Address QTY. MECHANICAL PERMIT FET; PLUMBING FEE
U I amity that 1 have teed this application and state Nat the above information is 9MECHANICAL FF.Ii
cora t. I agree to comply with all city and county ordinances and mate laws relating to PERMIT ISSUANCE.
tibuilding construction,and hereby authorize representatives of Nis city to enter upon the
L) z .brave-mentioned property for inspection proposes. ALTER OR ADD TO M I iCI L CONSTRUCI'IONT'AX
(We)agree to save,indemnify keep hurrobss the City of Cupcnino against
Ilabllities,jud a s,c.strando, nse hi hmayin any way accrue against said City AIR HANDLING UNIT'(TO 10,GW CFM)
muse cot thegramin If
^�Q C AIR HANDLING UNIT(OVER 10.000 CFM)
tgnmurer Applican4.n eta Bum EXHAUST]GOD(W/DUC'I)
_ PAID
HAZARDOUS MA'IF.RIAIS DISCLOSURE. HEATING UNIT(TO I loila1(1 BTU) Dam R
Will Ne applies.'or future Indicting decupcot surem handle hazardous bourflud
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Iloalth and Safety I]EATING UNIT(OVER 100.000 BTU) 1 AL.
Code.$CCllnn 25532(.)1
CI Yes ❑No VENTILATION FAN(SINGLE RESID)
Will Neappltmnorruas dell
bybenhis,Act.Air orJ bit, wM1ichemit
NOILER-COMP(BHP OR High) bRTI]) ISSUANCE DATE
• barvct? air conmmin:uns as definal by the Btry Area Air Quality Munagenm"t BOILER-COST OVER 100,000 BTU) p
Dimdml D
❑Yu ❑No NEW RESIDENTIAL MECH. SQ,FT.
I have read the hazardous materials requirements under Chapter 6.95 of the - NSI I/I
C.lifornlu Health&Sadely Code,Serino,25505,25533 and 25534. 1 Understand that /pV
J
if the building doesrant curadlY have.banner that it is my.,,...ibility a notify the /�� /
occupant of the requiremc as which must bmet e prior a issuance of a CeniEcme of
Occupancy. U
r
Owner ormahmimd agent Data TOTAL: ISSUED I3Y: t/ Q
OFFICE