27382APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUILDING - KLCIKICAL
PERMIT NO.
n
APPLICATION/PERMIT
PLUMBING -MECHANICAL
] % Q
27382
BUILDING DIVISION
BUILDING PROJEC'TIDEN'HFICATION
L r oG
BUILADING ADD 'SS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
4 ` , . �✓—
DNITM LO M Z
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WNGRS NAME: PIfONE:
C TRACTOR'S AME: LIC NO:
NIC
❑
NT
CONTROLp
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'DRRESS: •L ]
IP RCHITIiCTi1/EN'GSIrxNF.ER: LIC NO:
a3al Lax C cv. �rVe',4
CON 1';I� gr 0076wr PuoNE:
W
QTY; " ELECTRIC PERMIT PEE
BUILDING PERMIT INFO
B F PA MEC -
bI�J+•
5
V 110(
Ip ' $� PERMI'I'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
gppL1ANCE5-RESIULNTIAL
JOB UPSCRIPII ON
1 hereby a0ina thus I am licensed under provisionsof Chupter9 (commencing w11h
Section
full reandof DivisionJnf the Business and ProfessionsCWe, and my littnu is in PANELS
effmL
nee Clas
l License Class g
UP TO 200 AMPS
Con
i Date Commmor
201 - IIXIO AMPS
ARCHITECTS DECLARATION
OVER IOOOAMPS
SQ. PT. FLOOR AREA
$/SO. Ff.
• 1 undersand my plans shell be used as public record.
SIGNS ELECTRICAL.
j Licensed I4ofesiond
OWNER-BUILDERDECLARATIONthe Contractors
1 1 Law for he
L:
that I am exempt from the Cnmons
SPECIAL CIRCUIT/MISC.
�\�
ingreama(Semt
ng realeby n. (Se Businessandmpr Profusions Cock: Any city or county
I Co Any
TEMP. METER OR POLE INST.
which requires u permit re e.e
which to aper, improve, de lisp, m repair any
the umeamre
the applic cdpmm m
primeto slicensed
POWER DEVICES
pulsonttorequires
j that he is licensed pursue. m d sena of the o - License Lew (shaper
Limemgnedsahuide,
Ihm B.d
9 thatheise snit udOe Division3ofthe Buuincs and 'Anysions Code)i.l.linam
Section yacfromnt fthe hmmfomheallegctsthe p Ric di.m. Aivil Penalty of
by my
Sby anydresidamfmapertnit subjects the up Ric Ito ecivil Penalty of
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHIS- FIXTURIS
�a'1 V LUAU-TIO//N��ss �. /R�+�/
nm mLrcn Eve hundred Jollure($51YJ).
mora elf,
LCVVJ
❑ Lax. cmftheprnloodum,ri IIS..
NEW RESIDENTIAL ELECIR _ SQ. FT.
STORIES
TYPE CONSTRUCTION
amoymswithwagcaast 70mpensiness
offends nnl Business
willdothew k,Cde:
and Prmassi0 Cale: The Cnmmcmla License Law does not poly m on owner .f
The Curcisnmimendnse pply to an
not imaienedhroughhis
propertywh.byees,
OCC. GROUP
RES, UNITS
rsorimprat amb imon,ondentsam
ownuer.theos, immadk
not orof@rWforaala. IL
nlis
ingoriovided proveh )dwnthin or moeforpur,ama.wn -
ingorden di inot
builder
qnn
illhavi of,cmrngthat he build
bile.), will have ehurden of proving that he did not build ori rove for purpose of
sole.).
- -
❑ I,mowncro he propeny,umexdusiv y t tinIneed c.ntacd.n to
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
instruct the maje d (Sm. ]044. Businessros' t. C e The Comrucmr's
License Lawdoesn tapplymon.wacr.fpn .b vestlimenmand
PERMITISSUANCE
T
wh.comrams farm hpmjectswi c I v sedpursuam the museum's
PEE SUMM Y
ALTER-DRAIN&VIiNT WATER (GA
License l.aw. )
❑ I am excmp u ergs , B & P or this rcmon
BACK FLOW PROTECT. DEVICE
&F
SANITARY YID.
N
wncr D
Ie TPTq
WO MAN iNSAT1ON UECL TION
DRAINS- FLOOR. ROOF, AREA, GOND.
SCHOOLTAX N_
1 ❑ Thereby uffirmt tl hevee enificae nl'c.nsent el Ginsum, ora cenificme of
a
FIXTURES - PER TRAP
:CEIPfk
Wmken'Cumpcnsatio Insurance., u ceniBWcop mmf(Sm.380QLab C.)which
PARK FEE N
rsullemploym'sw c,nnapmoi
GAS-13A.SYSTIiM.I INC.40UTLETS
RF.CEIPTit
Policy g
G DIVISION PEES
PLA E .P. ` O
Company GAS - EA. SYSTEM OVER 4(EA)
❑ Certified copy is hereby ed.
❑ Cmified copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
GRADING F.- q
CERTIFICATE OF FXEMYr10N FROM WORKERS'
GREASETRAP
SOILS FEF.
COMPENSATION INSURANCE
(Thissoom neednm be completed ifthepermit is forme, hundred oullars($100)
SEWER - SANITARY - STORM EA. SBOPI.
ENERGY hili
+v
or less.)
I cmf dot India, pe,formuneear the work for which this permit is issued, l shall WATER HEATER W/VFNT/ELECTR
not employ any person in any manner so as to become subject to the Workers
PAID
Compensation Tmwsof Cdifomhc Data
WATER SYSTEMITREATING
Dale Receipt
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
become subject o the Worker's Compensation provisions of the Labor Cafe, you most
BUILDING FEE
forthwith comply with such provisions or this panni, shall be deemed revoked.
CONSI'RUCI'ION LENDING AGENCY
SEISMIC FFE 2
1 hereby infirm that hem is a construction lending agency for the performance of
ELECTRIC FEE
,an work f.r which this permit is issual (Sm. 3097, Civ. C.)
Lender's Name
Lender's Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
1 certify mut I hove read this application end state Oat die ahm, infnrmulino is
nett Iagre, to comply with ell city and county miinaneea and n6elaws reladinga
PERMIT ISSUANCfi
MF.CI IANICAL FIiE
building construction, and hereby authorize mpmamm iveaof this city a enteruPon dbe
above-mcmioned propeny for inspection purposes.
ALTRR OR ADD TO MECH.
CONSTRUCf10N'1'AX
(We) agree d. so., indemnify and keep harmless the City of Cupertino against
lodad w's, ju •meets, cnsa and expenses which may in any way accrucidPinat said City
AIR I IANDLI NO ON IT (TO 10.000 CFM)
in ee
c cof the gen'ng of this permit.
���
AIR HANDLING UNIT (OVER 10." CFM)
Signa of Applicam/Co mor Dam E%HAUSTHOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO IW,00) BTU)
Date l iota
Will the applicant or future building occupant store or handle hazardous material
as defined by Hm Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
HEATING UNIT (OVER I(IlI,WO BTU)
Code, Seaton 25532ho?
❑ yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
BOILER- COMP(JHP OR 100.010 BTU)
Will the applicanmrfuturcbuilding occupant useequipmcmordevices which<mit
arunims air mntaminants as defined by the Bay Area Air Quality Management
BOILER - COMP(OVER I(D,WD BTU)
R
❑ Yee ❑ No
NEW RESIUL'NTIAI. MECH.—SQ. IT.
1 have red the hazardous materials under Chapter 6.95 of the
M^Y �]
Seely Code, Sections 5505, 25533a shat
California Health&ot
25534.sibility
I[a
I �l
su a froun505at itis my responnd ntoti
ifthe building does nmcurrentlyhaveatenantshatitis mycefenotify
the requimmenta which must Me inn prior m Issuance of a Ccrtificnm o[
of
occupantupas
Occupancy.
y.
Owner or authunzed agent Dae
TISSUED
BY:
OFFIC