27598 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO DU I LVING FIFT DUCAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL A 7 ['9 O
BUILDING PROJF.CTIDENTIFICATION L J J o
Ii UILDINO ADDRHSS� �� SANITARYNO. APPLICATION SUBMITTAL DATE
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RCIII''113 1YIiNGINCIiR: LIC NO: ADDRF
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:QNTnc1': PHONE: QTY. "F,I,ECTRI P RMIT' - FEC BUILDING PERMIT INFO
IB�LDG ELECT M MECII
PERMIT ISSUANCE m ❑
LICENSED CONTRACfOR'SDECLClmpw,N APPLIANCES-RESIDENTIAL JOB DES IPDON
1 t00 Ihere0),I'tnthat l 3 ofthe sedBu undo pm professions
Coder and(commission,with
�i1,00 Semiore000)efDivision 3nfthe Business and Rofcssions Code,and my license is in PANELS
full CU Liremr e add Clens-(feel.
�6yy1 License Class Contrast
UP T0200 AMPS
44 d Dam ConTS D 201-I(NIO AMPS
ZO(md.Z ARCHITECTS DECLARATION OVER IM AMPS SQ.I'II FLOOR AREA $/$Q.IrI'.
O Z_p I understand my plans shall be used as public records.
W SIGNS ELECTRICAL
Licensed Pmtevninnal
OWNER BUILDER DECLARATION SPECIAL CMCUIT/MISC.
iySx�OaU 1 hereby affirm that I and exempt[,,,.,be Contractors License Law for the
W 30 o,ii following reason:Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
t LL Om 5 which requires a permit m smnspact,alf,,improve.demolish,or repair any sructure
prier to its issuance,also requires the applicant for such Femur to Ele a signed statement POWER DEVICES
W Kip that he is licensed parsuanuo the provisions of the Cotnraclnrs License Law(Chapter
tLao�' 9(commencing with Section 70)(1)of Division S of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt dumfound and the basis for the alleged exemption.Any violation of IJUTLITS-SWITCHRS-PIXTUR[S
ZQ Smlion 7031.5 by my applicant for a permit subjects the app)Tart to a civil penaltyof
not marc that rise hundred dollars($500). NEW RPSIDENTIAI.FIECIR -SQ.Ff.
CO
W�w ❑ oche wok,and the Sana,,imycmployeeswitheregesarthei(sole compensation, STORIES TYPE CONSTRUCTION
a will dotheand the he Co trader s Liced ense
Law ed for does not apply
to an owner
ss
of
and Professions Cade:The Comment(,License 1sw does or apply lf rt owner of
property wyeesho ,pdsodimproves th improand who are ssuch
endedomulfedforsghhisown OCC,GROUP RES.UNITS
employebuildi building
improvement
rsuch vemenprovcmwthin not intended forsale.If,
bowevegill buil dingasimpmvcmentissoldwithinoneyear or improve
for theowaer- 'TOTAL:
builder will have the burden o(proving that he did not build or improve for purpose of
sada).
❑ I,asownerofthepmpeny,amexcluslvelycmimm{ngwhh Ocen.e cmmearsm QTY. - 'PLUMBING PERMIT "FEE" FLOOD ZONE APN
construct the pnrjttt(Sec.744,Business and Professions Cade:)The Contractors
License Law dociantapply man own rofpmperty whubaddsorimpmvestherean,and PERMIT ISSUANCE
who contracts forsuch projects with o commcmr(s)licensed pursuan tomeConvacmrs
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ 1 vat exempt under Sec. ,B&P C for this reason BA PLOW PROTECT.DEVICE UTSI h
SANITARY Y N
Owner Date DRAINS-FT R.ROOT;AREA,GOND. RECENT
WORKMAN COMPHNSATION DECLARATION SCHOOL TAX Y_N
❑ Thereby affirm thutlhaveecenificam ofcansenno selGinsure,macertificete FIXTUNL(S-PI. TRAP RECEIPT is
Wmkeri Compensation Insurance oracenified copy thereof(Stt.lg00,IsbCJ nth PARK FEB Y N
raft employee's uMer Jusperad. GAS-EA.SYSTF -I INC.4 OUTLETS RECEIPT#
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTBM- ,R4(FA) PLANCHGCK FEE
❑ Certiflsd copy is hereby furnished.
❑ Certified cup,is filed with the city inspection divisor GREASEANDUSTRL WA INTERCEPTOR GRADING FEE
CERTIFICATE.OF EXEMPTION FRO WORKERSGREAS17TRAP SOILS FEE
COMPENSATION INSURA CH
('lllis section need mol be completed if @e pcmtiti for onehmdmddollars($100) EWER SANITARY-STORM HAJ2001`17. ENERGY FEE
one's.)
I certify that in the performance of the work for wh ch this permit is issued,)shall IEATER W/VIN /E.ECT
not employ my person in any manner so as to hec a subject to me Workers PAID
Compensation Lnwsof Culifomia. Date AT E ASYSTIs Date Rec' {p
7-+ Applicant
���--II C) NOTICE TO APPLICANT:If,after making this Cenificat of[buan,io , dNB ENTIAL PLMB. SQ.PT. TOTAL:
r 1p became subject the Worker's Compensation provisions®r the LaborC um
l� forthwith comply wilM1 such proviniuns or Ibis permit shell deemedrevoke BUILDING FEE
W z CONSTRUCTION LENDING AGingagE' Y SEISMIC FEE
^a Thereby off ism thud there ivoconslructlon lenAea, Ponhe#.dorn.....a -JDBLCLTRI l3C
V O the work for which this permit is issued(See 3097,Civ.C.)
Lender's Name
Lender's Address QTY. ,MECHANICALPERMIT `,.FEE PI. RING P:E
C) 1 cenify that 1 have read this application and slate that the -tion is
F CW-I coma.l agree to comply with all city and county ordinmcex and state laws relating in C .
PERMIT ISSUANCE M 'H IFEE
pj huilJingonmfrunion,and hereby xutharize represenfmives nfthis citytoemer open the
V z above mentioned property for inspection pur,ous. ALTER OR ADD TO MHCH. CONSTR 'TONT
(We)agree m save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,cnsts andexlwnse hichmayinaoywuylmerueagainstcad0ty AIR HANDLING UNIT(TO 10,0(X1 CFM)
sequence oflhe 6mn ilsbz�jthis t q c
_>_9J AIR HANDLING UNIT(OVER 101100 CFM) /
Signemm of Applica / Date IiXHAUST HOOD(WDUCq PAID
IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date eeeipl a
Will the applicant or future building occupam store or handle hazvdous materiel
m defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety HEATING UNI T(OVER FOR"BTI)) TOTAL:
Code,Section yi,s 'I ❑No 11 Yes a) VENTILATION FAN(SINGLEREBID)
ISSUANCE DATE
Will Neu applicant nfsee BOILER-COMP(JHPOR IOO,IKq BTU)
pp g by the qulpm it Quality Management t
hazardous airCI emtaminen(s an define-by the Day Area Air Qualify Mmugemcnt BOILER-COMP(OVER 100,000 BTU) !l A I D
Di541e1P r M
❑yes ❑No NEW RESIDENTIAL MECH.-SQ.FT. A
1 have read the harsrdaus materials requirements under Chapter 6.95 of the JAN 3 1995
California health&Safety Code,Sections 25505.25533 ad 25534. 1 understuad that
if the building does not currently have a tenant,that it is my responsibility to notify the
eventual of the requirements which must be met prim to issuance of a Cmificme of
Occupancy. l I- r rIIINU
Owner or amhorizW-gem Dale TOTAL: ISSUED BY:
OFFICE