27047 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO D.1,111FGTFI'eCTR PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27047.�O ^
III ILDING PROJECT'IDNIVI'IFIL'A'TION G 4
It UILLD^DINNG ADDRRnxF.SS!
1 v ,////yyy\��,,I/�,I10 J1/Y��A//' SANITARYNO. APPLICATION SUHMI]TAL DATE
V I Vl/a JWM v ' UNIT# LOT `�� 1��
O SNAME ve�1 COPITON': A 'S NAME 1.1 NfC CON9'ROhp
•ARCHRECT/ENGINEER: LIC NO: A RES _ '-- / ❑
CO ACT: PHONE f c ,� s s. _
QTY. , EI:EGfRIC PERMIT FET, - r",BUILDING PERMIT Iwo 'J
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 13 ❑ ❑ ❑
EN SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
OCZ Ihereby affluentlamlicensedunderpmvisionsof Chapter9(commencing with JOB DISCRIPI'ION
POO Section]000) of the Business f C e d my liave is in PANELS
�ZWE, Liceamvca and Ie 1 ).n
FZW Licenc 1 s Lic.p �� UP T0200AMPS \lrl2mwT
y G y Dale Convector 201-1000 AMPS
Z O y Z, ARCI IITECpS DF,C AR OVER 10(X1 AMPS SQ.Ff.FLOOR AREA $/SQ.Ff.
O Z^M 1 understand my plans shall be used as public records.
F,4 f_w SIGNS ELECTRICAL
N$ LieenrcA Professienel
OWNER-...map,
from he CmaTION SPECIAL CIRCUIT/MISC.
XOytJ I hereby n.(Se chat 1 am eacmpt from the GonCs License Law for Ne
W3LLy following reason.(Section 7031.5,Rosiness and ProfessionsCWe:Any city mcounty TEMP.METER OR POLE INST.
,
N 1 ON which rcyuirea u permit m comt.ober
truc ,improve,demolish,nr repair mw
y seture
�.Y7 prior to its isumce,also requhes the applicant nonsuch permit to file o signed statement POWER DEVICES
cull A O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a 9(crnmnencin t),Section]OW f Divisinn 3 oflhe Bminessand Proressions Code SWIMMINGPOOLELECTRIC
WMV, gwl )n ) VALUATION -
�Iy'�'my or that heisexempt
myap therefrom and the Permit
subjects the exlicant a civiny l
of OUTLETS-SWITCHES-FIXTURES
a,�t6 Sections71131.5 hy myapplicantantforapewit subjauthe applicantracivil penally of
net more than five hundred mil...($500) NEWRESIDENTIALELECTR _SQ.FT, f
❑ Lnsowner ant epmpeny,ormorionnyed oro engurealeinsole campcnsadon. ST'ORM'S TYPE CONSTRUCT'10
a3=° will dothewons andthe"o, ureisntrinmicense Law
dosnal not apply to an Business
and errywh),ns Code:Thr Contravesthe ost.Licence Luw rices or apply t),an owner of
propenywyees,provides]
improvesth improandwhndoessuchwork oroff nal for ughttis
own employees,pr),vidN that such improvemcnswc not intended proffereaforsme.If, OCG GROUP RES.UNITS
however,the building or improvement is sold within one yearofcampleame,the owner-
TOTAL:builderwillhavetheburdenofpproving that be did not build or improve for purpose
sale.).
QTY -y - PLUMBING PERMIT FEE IloaD ZONE nPN
❑
convince
the er),ftt(Sitehe rty,mm exclusivclycmramumsCding with e)Hedconntronto ,, s.
icente the project(Sec.]044,Business and Professions Cade:)ov'fle Contractors PERMIT ISSUANCE
Licenu I a w Jrxs not apply m an owner of pmperry who bui Ids or improves Nercnn,and
who contracts for such projects with acortmeemod Iicensecipnrsuant to the Contractors ALTER-DRAIN&VENT-WATER(EA)
License Law. FEE SUMMARY
❑ 1 am exempt under Sec. ,H&P C for this wean BACK FLOW PROTECT.DEVICE - .IDE FEEI
NITARY Y N
Owner RDRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCt10OLTAX Y N
• c❑ I berebyoffirm that l have a certificate ofcoment teself-insuar,macenificme of FIXTURES-PER TRAP RECEIPT#
Worker Cnmpcl'sa}jnr�IpSeC or lecedropyMvrcYl'(Sec.381)(1,LebCJ which PARK FEE N
era all em I,IN GAS-EA.SYSTEM-I WC.40 RECISION
Policy M BUILDING DIVISION FEES
Company GAS-P.A.SYSTIiM-OVER 4(FA) PLANCI liCK FEE
O gwifird copy i c y is ed.
,plICectified copy is filed wide the city inspection division. GREASTYINDUSTR,WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS ORLIASI3TRAP SOILS FEE
COMPFNSATION INSURANCE
phis section need not be completed ifthe permit is for one hundred dollar($100) SEWER-SANITARY-STORM EA.20017L ENERGY FEE
or less.)
I comfy that in the Performance of the work for which this Permit is issued,I shell WATER HEATER WNENT/ELECPR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensationlawsof Calif),mia. Date WATER SYSTENINREATING Dote Recciplq
z APplicv
� � NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Inbecoen subject to the Worker's CumpmaRtion provisions ofthe Labor Code,you must
forthwith comply with such provisions or this permit shall be decmed revoked. BUILDING FEE.
W (z CONSTRUCTION LENDING AGENCY SEISMIC FEE
5 1 hereby affirm that there is a construction lending agency for the perfomunrc of TOTAL:
U O the work for which this permit is issued(Sec.309].civ.C.) ELECTRIC FEE
Lendrr'a Name
OV Lrnaera Aadreaa QTY. ` `},t:MECI IANICALPERMIT, ' FEE PLUMBING FET:
CT) 1 rectify that 1 have read this application and aunt that the above information is ' " ECHANICAL TEP, 3�.
correct. l agree m comply wide all city and county ordinances and sate laws relating to PERMIT ISSUANCE
buildingItCO
in ,and herebyuuthodm mpresenutives of this city ee enter., the
U z abovemp perry for inspection purmacs. ALTERORADDTOMECH. CONSTRUCTION TAX
I.
ve,indemnify and keep harmless rhe City of Cupertino a most
co and expenses which meyinuny wey accrue ng mass Way AIR HANDLING UNIT(TO 10,000CFM)
1 tingofthispermit.
AIR HANDLING UNIT(OVER 10,1100 CFMI
Signemmo App¢anVCo or t EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATIiR1ALS DISCLOSURE HEATING UNIT IT I00pW BTU) Dme Receipt N
Will the applicant or form building nccupent seem or handle harmonious material HEATING UNIT(OVER IW,0R0 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chanute 9.12,and the Health and Safety
Code,Section 25532(0)?
CI Yes No
VENTIIA'I'ION PAN(SINGI.F,RESID)
❑
BOILER-COMP CHP OR I W,00f1 BTU) ISSUANCE DATE
Will rhe applicant nr fuwre building occupant use equipmentoNevicee which emit pp
M1avud),us sir contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P AID
D
District?
LCahf ❑Yes ❑No NEW RESIDENTIAL,MECIL SQ.FT. 1 0 1904
omiaHcalth
cowl the hamrdons mntedms"announces under Chapter 6.95 of the Nov'SI
alth&Safety Code,Sections 25505,25533 and 25534. 1 understand that
g dtws not currently have a tenant.that it is my responsibility to notify theIINU
he requirenteau which mum be met primm issuance ofa Cnific ua of C tar UUrtKVIIY hormd agent Date TOTAL: J 1SSUEDBY:
OFFICE