27114 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EL TRI Al. PERM1'I'NO.
APPLICATION/PERMIT PLUMBING-MEC-IIANICAI. 27114
BUILDING DIVISION BUH,DING PROJECT IUEN'DFICATION
BUILDTTIT
BUILDING ADDRESS: SANIARY NO. APPLICAION SUBMITTAL DA1'T
I1>'ISx UNIT# LOT
CL( �6
(RERS NAMEPACTOR'S N
_ : HONE: CONT ACTN LIC
•A RCHITECl/FNGINEF : LIC NO: ADDRESS:O 1hAtb0!q �J El
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEF, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL
I b70 affirm n3 of the
licensed p (commencing JOB DESCRIPTION
Section p e:Z Ya provisions of Cha mr9 commencin Ib
oe{t full Intoe and effmttnaon7o[m<Businesw Professions Cade,and my linos,is in PANELS A.. ��y
U, I.iceny tCl Cic.a� I UP T02W AMPS ` PN
J 1
U, Dam((J� Con[mcmr 201-IUW AMPS VAR
,)FOyZ ARCHITECT'S DECLARATION OVER I000 AMPS EQ.FT.FLUOR AREA ARF,A S/SQ.FT.
O Z_ I understand my plans shall be used us public records.
P y L w SIGNS ELECTRICAL
$,� Emended Pndcstiinnnl
OWNER BUILDER DECLARATION SPECIAL CIRCUIDMISC,
XI hereby-firm[hal I am exempt from the Comncm's License Law for the
WL t a y following rcxson.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1"4O; which requires u permit to construct,alter,improve,demolish,or repair any sirdar,
Prioe 1.its issuance,also requires theapplicant fn-lch pear it to filen signed,notemenl POWER DEVICES
m LY G p that he is licensed pursuant to the provisions of the Comracmr'a License Law(Chapter
ey 9(commencing with Section 7")of Division 3 of the Business and Professions code) SWIMMING POOL ELECTRIC
VALUATION
�Z^
or that h7031.5 by myapplicantfra permit subevllegeJexcmption.A civil Penalty
of OUTLETS-SWITCHES-PI RES
F Z Q Section ilaw is any applicant fora permit subjects me applicant m a civil penalty of
�R0
nut more mum fisc hundred dollars(5500). NEW RESIDENTIon, AL E S PT.
pet:p ❑ oche wrk.wnde he
eisa.,mployas .fillrgesasalei See.compensiiess Q STORIES TYPE CONSTRUCTION
pW„3 will dolhewons and the he Co lowlea im kende Law doeod s of apply to am Business
pandro Professions Cade:The Contnemrs License Law does or apply to an owner of
is
propcnywbob,provied that suchieon,andwhodermintende oroff mdthroughhis
employees,providedmpr improvement
of ewoedapletiod for ole. r. OCC.GROUP RES.UNITS
however,thebuilding orden orvemen[issold withinoneyear of completion,due owner. TOTAL'
builder will have the burden of posing mat he did not build m improve for purpose of
sale.). TY. PLUMBING PERMIT
❑ Iict he erofine Sec.7y,am exdusis it
Cnci)tThe Contracrsto Q FE FLOOD%ONE APN
wconstrict the projcc[(Sec.oano Business and Professions Cenci)The Contractors
hocxetrawdasndapplymawithacofpropenywhosedpuoment tovtheCut n,and PERMIT ISSUANCE
who contracts Law. ormeb projects with aconuazmr(s)licenud punuanuo the Conine ALTER-DRAIN&V A (GA)
L"`nae Law. FEE SUMMARY
❑ I am escrept under Sa. ,B&P C for mix won
BACK FLOW PROIT ICE OUTSIDE PEES
NITARY YN
Owner DatelocialrURAI -F F,AREA,CON Rf;CEIYF#
WORKMAN COMPENSATIONUECLARATION �1001.TAX YN
❑ em'Co affirmthnllsumnect)r fi,aifi,donsemhave aecte mfum,,f(Sneure,o,L.b C.)w of FlXT t TRAP RECEIPT#
.Worken'Cnmfxnvnion Tnsumnee nroccrificA Dopy mercaf(Sea 3ft0,Lab C.)wb h PARK FEE Y N
rs an err a , a r t , roto C. Rre a
cove""'
1 GAS-E S TEM- NC. OUT 7
BUILDING DI ISION ES
Company GAS-EA. TEM- V R4(BA)
❑ Certified copy is hereby famished. ('A) PLANCIIECK FEE
Ccmficd copy is fled with the city inspection division. GREASEANDUSTRL WASTE I RCEPfOR
GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF,
COMPENSATION INSURANCE
Crnis section need not be completed ifthe permit is foram,hundred dollars(S10) SEWER-SANITARY- ORM EA.2041 ENERGY
lean.)
I certify that in the Performance ofthe work for which 1i rmit is issued,l shall WATER HEATER ENT/ELECTR
not employ any Person m any manner so as m to subject to the Workers' PAI
zCompensmionlawsof California. Dae TER SYST /TREATING
Applicant Date ReaiptN
Q
z NOTICE TO APPLICAN7>1,N¢r making this Cmi6catc of Eaemption,you should NE ENTIAL PLMB. SQ.FT TOTAL:
H y
become subject the ker'e Compensation provisions of the labor Cale,you must
a 7 forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
1 CONSTRUCTION LENDING 6,C. �Y SEISMIC FEE
z l herebyaffirmmanhent a con:mica mg agency for me perfmman<e of
V O me work for which this permit is iss a.3091,Ci,C.) TOTAL: ELECTRIC FEE
Lender's Name
OU Lender,Address QTY. MECHANICAL PERMIT' FEE PLUMBING FEE
>" W 1 certify that 1 have read This application mid some mm the above information is
F^ a correct.Iagreemmmply with ell city and county ordinanc,r and smmlaws relatingm FERMII F ISSUANCE MECHANICALFE
_ fO building construction.and herd aahoom representatives u(thiscity menterepon the
f,J 'z above-memiomed propcny for inspection purposes. ALTER OR ADD TO MECIL CONSTRUCTIO TAX
(We)sgra to save Indemnify and kap harmless me City of Cupertino against
liuhili[ies.judgmect,costy and penses which may in any way accrue against said City AIR HANDLING UNITTO 10,"CFM)
'ecomcquenecof[hegmntingo Nispernit.
�6 ^ AIR HANDLING UNIT(OVER 10,00 CFM)
SignmmrenfA -cont/Comrndne ale V EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALSDISCLOSURE
ware OSURE HEATING UNIT(1'010,110 BTU) Dam R eiptp
Will the applicant or Enure building occupant er 9.or handle laminations Helth and
usdefincdio the32pcnino Mu
Code.Chapter 9.12.and Jte Health and Safay ❑EATING UNIT(OVER 10,000 BTU) TA
Code.Sectio"25532(a)p A /
C3 Yes Nn VENTILATION FAN(SINGLE RFSID)
Will he appficnnlnr route buildingwc....I use elmmocn[ordeviccs which emit BOILER-COMP(3HP OR 100.000 BTU) ISSUANC ATE
ha>allous we canomironu az defined by the Bay Area Air Quality Management =MCCH._
intim?
❑Yes r No I base read the hareardous m d.m.1,reirememe under Chapter 6.95 of the ®�� �gg�
CaliforniaIlnallh&SufctyCWc,Sections25505,25533ad25534. 1understand thatif the building does not cunendy h; enlenanL@m it is mretonsibilitifhccupamof therequiremems whid ousel M met rior to issuance ofa Ccoif to ofI a. ' UrWOwnerorat carved m s D : ISSUED RV:
OFFICE