27662 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUIILING-ELLEU I HICAL PERMIT NO.
APPLICATION/PERMIT PLUMBINROJG.-MECHANICAL. 27662��� L^
BUILDING DIVISION BUILDING PECT IDENL'I'EFICAI ION
BUILDING ADDRESS: ,1 SANITARY NO. APPLICATIONSUBMIDTALDATE
/ APH s UNITp LOTq
NERSN H:
PHONE C N'fRACC11 f/LOR'S NAM LIC
LIC NO:
V 'f0[/ k1L UII VL Ohs/
NIC CONTROLp
RCH'I'H /ENGINEER: LIC NO: ADDRESS: ❑
C AaoC./A&16 la$ Cor %��t - 41"1-Zoo
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
NORM 14 µo -40,,2{g-66 6 Q RLDG EI.ECI' PLUMB MI:CII
PERMIT ISSUANCE El \CA
T
El 0
LICENSED CON'RACTOR'S DECLARA'T'ION APPLIANCES-RESIDENTIAL �Y
I]mz flacchyuf.rmlhnt lam licensed tnderprovki.m.l'Chaser 9 hour acncingwith IOH DESCRIPTION
Mico Somata 9000)of Division 3 of the B uslnces and Professions Coda,and my license is in PANELS
Fzw
License Clads Lic.N UPT02W AMPS
m=y Date Commctor 201-1000 AMPS
z�NZ ARCHIDECLARATION OVER 1000AMP5
TECTS SQ.PT.FLOOR AREA S/SQ.II'.
OZ-0 1 understand my plans shall M used as public records.
re�+,
_E W SIGNS ELECTRICAL
Iaad Licensed Prefim,i...I
(rlIW OWNER-BUILUUR DECLARATION SPECIAL CIRCUI'DMISC.
yx OaU I hereby.Marta Ilial 1 tan exempt from the Contractor's License Law for the
Ovr following reisun.(Scene.9031.5,Business and Professions Cade:Any city or county / TEMP.METER OR POLE INST.
ti—
to� which actuates a Famor to construct,alter,improve,demolish,or¢pair any structure
.Ir�lk`
:E to prion.iu issuance,a],.requires lheipplicint forsuch pemliuo Nen signed statement POWER DEVICES
ly C p that he is Ikaned pursuant to the provisions of the Conlmnors License Law(Chapter
sap 9(commencing with Section 7")of Division 3 of Ne Business midProfessions Cade) SWIMMING POOL ELECTRICFIXTURVALUATION
y_y or that he is exempt therefrom and the bola for the alleged exemption.Any violation of OUILEI'S-SWITCIIES- ES
112 Section 7031.5 by any applicant for.pcrnitsdbjc,.theapplicam to.civil penally of
G not more than five hundred dollar,($511(1). NEW RESIDENTIAL ELECI'k _SQ.1• .
M ❑ I,usnwnerofthepmp rty,armyemployceswithwagesastheirsolecompensation, STORIES TYPECONSTRUC'IION
0
will do thework,and Restructure isnot inundedmitffared for auto(Sea.7044,Business
and Professions Code:The Contractor's License Law does not apply in on owner of
pmpenywhobuildsofimpmvesthea n,andwhod«ssuchwafkhimxelfort moghhis
If. C OCGROUP EUNIhowever,the building orimprovement in sold within one yearofcompledon,the owner. TOTAL:
builder will have the burden of proving that he did not build or improve far purpose of
sole.). -I,as awncruftproperly,am exclusively contracting with licensed wiffiacmrs to QTY' 'PLUMBING PERMIT FEE FLOOD ZONE
construct the project(Sea.0044,Business and Professions Code:)*Me Contractors -
License Law docsmm apply car an ownerofpropeny who builds or improves thereon,and PERMIT ISSUANCE
who cataracts forsuch ptnjecta wife a convadorts)licensed pumantto the Contractor's
Licex Law. ALTER-DRAIN&VONT-WATER(PA) PEE SUMMARY
EIni am exempt under Sec. ,B&P C for Nis reason S ,FEES
BACK FLOW PROTECT'.DEVICE
SANITARY Y—N
-
Owner Date RI3CEIPTN
DRAINS-FLOOR,ROOF.AREA,COND.
WORKMAN COMPEanto ofIONDECLAR-inati N SCIIOOL TAX Y N
❑ era Co afprmO Insurance I have. or a fano of consenuacl(Sce.m,or oar,C.) hickle of RIiCEII'l'N
Workere'Cmnpmtsmion Insurance orucenificd copy thereof(Seu.3g(1U,Lab C.)which FI%TURFS-PERTRAI' PARK FEE YN
van nl1 entployecy,unde tITsyeryyl4 GAS-EA.SYS'I'IiM-I INC.4 OUTLETS BUILDING r VISION FiES
Policyp C•f d l tf
Company C I A /O GAS-EA.SYSTEM OVER 4(EA) PLMs CHECK FEE
❑ Certified copy ishemby furnished.
❑ Certified copy is Bled with the city inspection division. GREASERNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPUNSATION INSURANCE
(TUissection redact be completed lfthepamll is fur one hundred dollars($100) SUWER-SANITARY-S'I'URM EA.200111'. BN ERG FEE
or Ices.)
I eanify that lathe perfoamenceof the work for which this —it is issued,is hall WATER HEATER W/VENT/P.LECTR
not employ any person in any manner an m an become subject to the Workers' PAID
z Compensationlnwsof California. Dale WATER SYSTEM/IRHATING Dam Receipt#
Applicant
Q 0 NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you should NEW RESIDENTIAL TIME. SQ,IT. TOTAL:
I—� t,f become subject to the Workers Compensation provisions of the LaMtr Code.you must
; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
P, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q Z I herehy affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work fur which this permit is issued(Sec.3099,Co.C.)
Lenders Num.
C) F tenders Address QrY. MECIIANICALPERMIT FEE PLUMBING FEE
U T certify that I have rand this application and state that the above information is MECIIANICAL FEE
comet, I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
U Z bulldingc.nstruction,andhereby authorizercpresenmtivesofahiscilytoenwrupon the CONSTRUCTION TAX
uWve-nsminnwl property for inspection purposes. ALTER OR ADD 90 MUCH.
(We)ogre,to save,indecently and keep harmless the City of Cupadhm against
liabilities,jadgntenta.coslaand expenses which may in any way accrue against said City AIR HANDLING UNIT'(TO 10.000 CFM)
im m�seyucnce of the granting oftbie permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of ApplicanUContranor Dale EXHAUST HOOD(W/DUCG PAID
T IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(T01W,OW BTU) Date ReceiptN
Will the applicant or future building occupant store or handle onardous material
asdclincdbythe Cupcnino Municipal Code,Chapter 9.12,and the health and Safety IIEAT'ING UNI'1'(OVliµ100,000131U)'' '1'O"
Code,Section 2.5532(a)1 -
❑,Yes 50 No VENTILATION FAN(SINGLE RE51D)
ISSUANCE DATE
Will the.pplicamerfmure Building«cupantuucquipmem nrdevices whichemit BOILER-COMPOHPOR 100,000BTU) p
�Imrardotls air communanu as defined by the Bay Ana Air Quality Management BOILER-COMP(OVER 1W,OW irru) PAI Diao-inY ' M 0 P\
❑V`s QS No NEW RESIDIvYI'IAL MECH. SQ.IT. n V
1 have road the hmardaus materials requirements order Chapter 6.95 of the NO if --F U ��
California health&Safety Code.Sections 25505,25533 and 25534. 1 understand that �!! v
if the building does not currently have a tenant,that it is my responsibility he notify the
ca upon.1 the requirements which most M met prior m issuance of is Cenificam of
0C 'assay IAILLVN.Nn Ivor" 0 Iq9
OwWcrur 11hredagent Odra 2� TOTAL: ISSUED BY:
OFFICE