27054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICAL PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27054
BUILDING DIVISION BUILDING PROJECTIDEN'I IFICATION --
❑ LDING ADDRESS: ,I SANITARY N0. APPLICATIONSUBMII�FTAL 1DATE
I V�� IINITil LOT# ^ r\ y{fir
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A CIIITE iNGINF.ER: LI O: S'!�a!" A DRESS
CONTACT: PHONE: x¢11✓ U J'e BUILDING PERMIT INFO
QTY. F C PYRMIT FEE
BLDG •LOCI' PB MECH
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— PERMIT ISSUANCE �aILD
LICENSED CONTRACT R'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Matz Ihembyaffirm that l ate licensed under pmvisiansof Chaprer9(cOarmarng with
PJ00 Scclion 9000)of Division 3ofrhe aminessand l4nfeasions Cale,and my license is iu PANELS
¢U� fi lumecand effete.
F.ZW Licence Class Licx UPTO 2M AMPS Q Q111, '�
toQ-C/I Dale Carlraaor 201-I(IOOAMI'S SFV �•�/
7ONZL ARCHITECTS DECLARATION OVER I000 AMPS SQ.PC FLUOR AREA $/SQ.FT.
O
Z-0 I understand my plans shall be used as public records. fA
i-rn W SIGNS ELECENICAL �t4�- a(-
Q j Licensed Pmfeaeional � ��\\\\
L d'6
OWNER-BUILDERDECLARATIONSPECIAI.CIRCUIT/MISC.
iqq��(OLF 1 hereby n.(S that 1 am exempt from rM1e Cmirtarma'a Co License city
Fertile
li]'T W y fullmwhich idguires a e mit to 9031.9.Business and Professions h,or re to city rn county TEMP.METER OR roLP.INST.
E: which requires a permit to conawa,alter,improve,demolish,or repair any structure
}� pricer to its issuance,also rcyuirxs the applicant forauch permiuo Bleasigned mm satecPOWER DEVICES
Q O 11 1 he is llareeA pursunot to]to provisions of the Contractors License Law(Chapter
aL00L 9(nmmnencing with Section 7")of Division 3ofthe Busidearaid Professions Code) SWIMMING POOL ELECTRIC w VALUATION,
,-y
,ZQorill.,heisexempt themfmmnand the besiturtle pealexempltonviolation of
SoLShysay appPermit subjects the to civil Penalty of OUTLETS-SWITCHES-EIXTlRLS
r�L 0
nolumon thin five hundred dollars($ANO.
^o ❑ LasownerolI eproperty,ormyetnployeeswirh wages as thcirsolecompensation, NEW RESIDIeNIAL ELECTR _SQ. S'IORIFS TYPECONSI'RUCTTON
willditme walk,and rhesuvaumis not mourdedenuffcred for as(See70,14.Business
and Professions Code:The Counselors License law does not apply to an owner of
t properly who builds Or improves therenn,und whodoes such work himselfor through his
own employees,provided that such improvements me notimcadedoroffescl Include.If, OCC.CROUP RES.UNITS
however,the buildingor improvement is sold within oneyearo(completion,the owner- T I:
builder will have the burden ofpmving that he did not build or improve for purpose of
a).
❑ I,aaowderarlh6prapeny,am exclusively contracting with licensed contractors m QTY.'; PLUMBING PERMIT .FP.E . ELooD ZONE nPN
Consumer the project Sch.9014,Business and Professions Gude:)Ttm Commerce, PERMIT ISSUANCE
License Law does not applyto an owner of timomy who builds or improves thereon,and
who commits for such projects with acontracmtis)licensed pursuant o the Contractor
Llcmtse Low. ACIER-DRAIN@VER - ER(BA) •PEE SUMMARY,�'�r
❑ 1 am exempt under Sec. B @ P C for this Wesson BACK FLOW PROTECT. P. S pF.F.•.
SANITARY Y N
Owner Date OOF,A RRECEIPT X
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL TAX Y_N
❑ Hereby eno'Conflon affirm rhmnhave a urance ore certificatesidentical
pythmm'Sesure,0,laMCertificate.)which
PI%TUNES-1'ER TRAP RECEIPI'tl
Workers Compensation Insurance oracrnified copy thereoflSec.3800,1.ab CJ which PARK FEE YN
Covers all employees under this permit. GAS EA.SYSTEM-I1 4O RECEIPT'X
Policy It BU IN DIVISIQK FEES
Company GAS-EA.SYSTIA/-OVER4
❑ Certified copy is hereby famished. (' PIANCHECK PE: 0
❑ Certified copy is filed with lhecity inspection Division. GRIASEANDUSTRL WASTE INTERC GRADIN I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS Fh' a
COMPENSATION INSURANCE �
Obis section neednut be completed ifthe permit is far..hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEC
ar Ices.)
Icenilyfhatin Oto lter0stmanec ofthe work lite which thispermitis isnucJ,lshall WATER HEATER W/VGN I MLECTR
nor employ any person in any manner so as to become subject m the Worker.' PAID
Compensationlawsof Califumiz. Date WATER SYSTBMGTEtTING r k ei
p Z Applicant
7-. 0 bit ICETO APPLICANT:ILafrernmking this Cenifcan;ol'Exemption,you should NEW RESID17WTAL PLMB. SQ.FT. l'O9'AL:
ry becmmucia jectatrhe Worker's Compensation provisions of the labor Cale.you must
a 7 forthwith comply widrsuch provisions or this perch shall be deemed revoked. BUILDI GF ?
W z CONSTRUCTION LENDING AGENCY SP CP.;
^a I hereby affirm that hem is a construction lending agency for the performance of
Uthe work for which this permit is issued(Sec.3097.Civ.C.) f: IC aE
L>~ P Lender's Name. I c mac
U Lcndcr's Adores QTY: MIiCHANICAI PERMIT' „y'. TTG PLUMB
1 terrify Wm 1 have read this application and state that the above information is '
carrier.In to comply with all cit yo g MECH ICALFEG
agree pyhe yard count Ntives oaend stem(earsr upon to PIiNMI'f ISSUANCE
h Z buildingcotioned oo,and hcrcbypection p lip ses. vas of this city to<nmr upon the CON MUCIION TAX
Uz above-mentioned agnea properly,for inspection purposes. - ALTERORADUTOMCCfI.
(We)agree m save,indemnify and keep taintless the Cify of Cuperlinn against
liubilities,jud cro'covs and pease,which way acomia insI id C51y AIR HANDLING UNIT(TO 10,000 CFM)
Irconuq eof the gntLi
�t �s AIR HANDLING UNIT(OVER 10,IX0 CFM)
Signature of Applican nthwbr f!J D`id; EX I TAUST I IOOD(W/DUCI')
PA
HAZARDOUS MATF.RI .S DISCLOSURE HFATING UNIT(TO 100,000 BTU) Data ipt
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT'(OVER IIXI,(IW BTU] T
as defined by 1116 Cupertino Municipal Cafe,Chapter 9.12,and the Health and Safety
Cale,Sectim. ON
o Y s ❑No32(e)P VENTILATION PAN(SINGLE RFSID)
Will thea Bouncer lumrebuildin BOILER-COMP(31IF OR IM."Bl'U) ISSU DATE
pp goccupem uecegoipmcm ardevices whichemit
amrdous air contaminate as defined by the Day Area Air Quality Managemem BOILER-COMP(OVER 100,000 BTU)
tj.IncIT ,p,p��
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. P I
A
I have teed the M1az Code.disto materials 5505.25533 odder Chapter enti of the
if the uil ing lthdo s Safety Cede.Sections 25505,23533 andsponsi 1understand mat
ifrhebuilding Anesnot mnts whaveatenant,thmitis my responsibility of
enotify the DECG
Ofecisnf of the requirements which must be met prior m issuance of a Certificate of
Occupancy. �
Owner or amhorizN agent Date 'f0 AL: ISSUED BY:
�Y'1`NIIIVU
OFFICE