27883 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
° CITY OF CUPERTINO - RICA, PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECIIANICAI. 7 8 8/(�V
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUIL gpDB1;SS:8 � y�%. y$,���/yr/y UNIL# OT M/ry SANITARY NO. A/PVPh_{ICATI�ON SU�B•1/MI'1-1'ACUATE
( :3%LYi: !//7/ V\// CJS/!/ C RA M M_
N/C CONTROL#
Islip\R I E 1 m ` p /�
DN a : PHONE: 1/' BUILDING PERMIT INFO
���� ��� QTY. ELE RIC PERMIT FEE
BLDG ELECT M MECH
PERMIT ISSUANCE El 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Maz Ihembyaftilmlhatl um licensed under OrovisirnsofChupmr9(commencing wish JOB DESCRIPTION
+{100 Section 7")of Division 3 of the Business and Professions Code,and my license is in PANELS a
aVl- rAlfome and err
p.zw License s Lia# D V o UP TO 200 AMPS
yQh Dal[ Convector 201.tOW S
,)pNunZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA $/SQ.FT.
04• Jersmnd my plans sM1sll be usedazpublic records.
rr' L� SIGNS ELECTRICAL
6y�j Licensed Professional
K�yQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
5°5diOaU I hereby affirm that 1 um exempt from the Contractors License Law for the
u1rFi1 following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER INST.
F_0 which requires a permit to construct,alter,improve.demolish,or repair any sanctum
S_ Y5 prior to its issuance,also acquires the applicant fill such Permit 0 file a signed statement
POWEJ DEVICES
K O
that he is licensed pursuant o the provisions of the Cortra nn's License law(Cooper
d 9(commencing with Section 70fil or Division 3 of Ne Businss eand Professions Code) SWIM GPOOL ELECTRIC
XmLL VALUATION
w_rn or that he is exempt M1erefmm and the basis for the alleged exemption.Any viclationof OUTLET -SWITCH -FIXT S
�Z¢ Section 7031.5 6y any to fora penah.,objocts the applicant m a civil br ally of
not more than five hundred dollars($5W).
KFp ❑ 1,asownerofthepmpwy,ormyemploymswitwugeswtheirsolecompensmion, NEW RES ENTIALE SQ.FT. STORIES TYPE CONSTRUCT ION
y,3�° will dolhcwork,Came inCmcisaodr Liced,Lawrdoes salc($ca.WYW, wus"n,of
unJ Professions Axle:Tho,Contractors Limnu law does not apply m an owner of
propcny whobuildsarimpmves tereon.and whodms such work himselforNmughhis
employces,provided that such improvements tharenol intended orofrered forsale.IL OCG GROUT' RES.UNIIS
however,the building or improvement is sold within one year of completion,the owner- TOTA
builder will have e burden of proving that he did not build or improve for purpose of
sale.).
❑ Las owner of the properly.am exclusively contracting with licensixteemmClorsm QTY. PLUM H CPERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044.Business and Professions Code:)The Comment's
License laved«snot apply m an uwnerofprop[ny vombuilds orimproveitherenn,and PERMIT ISSUANCE
who contracts forsueh projects with acnntractugs)licensed pursuanuo the Contractor's
License Law. ALTER-DRAIN&VP WATER(FA) FEE SUMMARY
❑ 1 em exempt under Su. B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner DateSANITARY Y_N_
DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_ry
❑ "hereby a lrwthatllwveacenificamofconsennoulf.insum,oramnificateof FIXTURES-PER TRAP RECEIPT'#
nrkeri Compensmion Immorecola ceniGedcmpy lherenr(Sce.38W,Lab CJwhich PARK FEE Y N
so
sets
all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy#
company I BUILDING DIVISION FEES
❑ Cenilicd copy i.hereby fumisl / GAS-GA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed with cityinspwtfondivision.
GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICA".OF EXEM ON FROM WORKER. GREASETRAP .OILS FEF.
MPENSAT INSURANCE
Thilaceminnced 11comin a iftepcamit is for one hurMred dollars(EI W) MPLMB.-
-STORM EA.2WF1'. ENERGY FEE
or hese.)
Icenifythatln a ofdo wor r tispermilisissued.1shall VENT/ELECIR
nm employ any out abject to to Workers' PAID
Compensation, PATING
Z a eDole Receipt#
Applicant
O 0 NOTICET PP of r raising this Cemificate of Exemption,you should PLMB. SQ.FT. TOTAh:rn Iccmnesa colt o stmorpmvisionsoftheLabraCode,ywmauforthwith omp ilnsuc rthis,rantshallbedeemedmvoked. BUILDING FEE
C STRU onON LENDING AGENCYSEISMIC FEE
zhereby affirm tthemis onsvuction lending agency forthe performance of
dm irkforwbic is permit' issued(Sec.3197,Civ.C.) L ELECTRIC FEE
Le dens Name
U' F I dicesAdd s QTY.=EXIIAVSTHOOD(W/DU�)
HANICAL PERMIT Pgg PLUMBING EBG
U 1 cerli 'hat I ha read tis applicmion end smm ve information is
�" OW.. meet. I' tic Iywitallcily aortic mares and state laws relating to NCE MECHANICAL FEE
F-' � buildin .and thereby. mmpraenutivesofthiscitymenteruponthe
U z opcnyf spectim,purpose.,. D TO MECH. CONSTRUCTION TAX
ndemnify and keep harmless the City of Cupertino against
lie ,j4 costs andexpenus which may in any wayaccme against said City UNIT 10.000 CFM)
4 c eraming of this'mm"
UNIT(OVER 10.000 CFM)
of Appli VCommcnr Dale D(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,IXIp BTU) Dam RaciptN
Will the plicwl mrfuwre building rzcupanl score or handle hazardous material
as Jethro, the CupertinoMwrirmal Cwlc,C1aplen9.l2,amJ the Health and Safely HEATING UNIT(OVER IW,(XX)BTU) T TAL:
C a, ectimn25532m)7
❑Yes ❑No VENTILATION FAN(SINGLE RESID)
Will teapplictoomfumrc huildingszcupanmseequipmenmrdeviceswhichemh BOILER-COMP(3HPORI)r,fKK1BTU) APR D E
t sea ser contvninanu az defined by the Bay Area Air Quality Management
istricv BOILER-COMP(OVER 100.00t)BTU) APR 'fn
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 199
clay 5
I have read the fm1,C m materials requirements under 31 l err 6.95 of the Uf
eamnmia neaten&saray code,s«Iron..zssos.25533 and zss34. wnnerslm,a ma' LurrHrll�l\��A�/[J//
iolhe buildinge hapir ersems which
a must
be.radios my suanceibf a C, ifica
aupant of the requiremenu which muss be met prior Ira issuance of a Cenifinte of
txcupancy. 1
Owner or amhonzed,gem Die TOTAL: ISSUED BY:
0