27686APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILDI G- VI,EC'IRICAL
APPLICATION /PERMIT PLUMBING - MECHANICAL.
HUILUINO DIVISION BUILDING PROJECTIDENN IPICA'ILION
PERMIT NO.
27686
BUILDING ADDRESS: !✓� I 1 / r
/ 9 37 S el.e is C K i AT
UNIT# k OT'#
SANITARY NO.
APPI.ICA'IION SUBMITTAL. DATE
OWNERS MF.: �'' PHONE:
/(S Sa+q k/h $
_
CONT'RACTOR-'SSiN�AMEi �LkIC NO:
/fl I# - /ree � g1.7 �vLc'IC -C 475%
N/C
❑
CONTROI.x
IARCfIITEL'I' GINF.EN: LIC NO:
ADO OI- Pya I_�m 7 AO
,,++ GOC. S
1 -/1 I / {1 ONE `
CONI'ACI'; CD9)fi 7, 1-- 1�
�_iae✓Qe ( /IG ✓l u1
��'' ��
QTY,
ELECTRIC PERMIT _
17EE
BUILDING PF:RMIT'INPO
BLDG ELECT PLUMB MI3CIi
PERMIT ISSUANCE,
``++
��
LICENSED CONTRACTOR'S DECLARATION
1 hereby aff Ire Thal 1 am licensed under pnwisinnaof Chapl «9 (commerical, with
APPLIANCES - RESIDENTIAL
IOtl DF_SCNIPI'ION
Section 9(Ng)of Division 3 afthc Business and Pmfe,niors Code. and my license is in
Lirensc Clue � .p �� 97
PANELS
UPT02MAMPS
Dent Convenor
201 - HSMI AMT'S
RCIII: ECTS DECLARA'ION
I understand my plans shall be, used as public records.
OVER 1(gO AMPS
SQ. Iff. FLOOR AREA
5/SQ. PT.
/
SIGNS ELECTRICAL
Licensed Pm &ssinnel
OWNER-BUILDER DECLARATION
SPF,CIAI. CIRCUIT/MISC.
I hereby or that 13L exempt Bom the Contractor. License Lew for the
TI:MP.MFfEROR POI.Ei INS'f.
(Se Professions GUle: Any city ter county
permit
whichingreason.(Seit to consumer, alter,
which require comwn, alter, improve, demolish, or repair any structure
n re
Prierte its issuance. heemorro frno such permit to stntemmn
POWER DEVICES
Mrsomt 1. the Licese La
That he is ncing w th Section m the provisions of the Co Brain c License Low (Chapter
9(commencing with Smtinn l00o)af Division 3nf Ne Rosiness and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section ]N 1.5 by any applicant for a permit subjects the applicant to a civil Penally of
��1/�A��y
OUTLITfS- SWITCHES - FIXTURES
nor more than five hundred dollars (8500)
❑ 1, asownerofthepropny. ormyemploymswithwagesastheinalecompensation,
LL.({�.(e
NEAVRESIDEN'r1ALELECTR_SQ.FT.
STORIES
'I'YPECONSTRUCI'ION
will dothework, and the structure isnot intended oroffered for sale (See iaaa, Business
and Professions Code: 'I'he Contractor 'a License Law does not apply to an owner of
property whobuildsorimpmvex Ihereon,md whnd,es each work himulforthrough his
enadoyeea,providvv1mm such immovemenla are nm interiedorufferedforsale. IL
I
C. CROUP
RfS. UNITS
however,the buildingor impmvemmt is cold within one yearofcompletim, the owner -
builder will have the burden misusing that he did not build or improve far purpose of
QTY'
PLUMBING PI7RMIT -
PEE
sale.).
❑ hmownerof the proprny,em exdusivelycenuncting with licrnud<onwcmmo
FLOODZONR
APN
construct the project (Sec. 7044, Business and Professions Code:)'rne Contractors
License Lawdoesnot apply to an ownendpropcny who builds orimpmees thereon , and
PHRMITISSUANCE
whocontrmtsf orsuchprojmtswithaconmetofs )Iicena pursumtlothe Contractors
.ecasa Utw.
ALTER VENT -WATER A )
FEE SUMMARY
❑ 1 am exempt under Sm. , B & PC for this reason
BAC
P OTGCT. DEV ICB
11
T h FIR S
SANITARY Y N
RIiCF.II'l'#
Owner Date
-
DRAT S- FLODR.
ROOF,A aaDl
WORKMAN COMPENSATION DECLARATION
'❑ (hereby affirm that l have a certificate ofecosenno self-mum, or a certificate of
Workers Compensation Insurance ors certified co themof(Sec. 3X00. Lab C.) which
pe copy
SCHOOL TAX Y
RECEIPT'#
FIXT)RI) {PERiTli r'
r
PAItK FEE Y N
GAS -EA. SYSTEM -I Iffy
oriveraidl employe{ rthsOwrett�G�Z / I OZ
L✓ 7
RECEIPT
BUII GDIV .S
PLANCIIECK LEE
Com an ✓� an e'en '*""
Ir: _
`AS
� Cmifiedcopyishereby famished. I
GREASH /INDUSTRI. WASTE INTERCEPTOR
—"/
GRADING THE
❑ Cenifcd copy is fled with the city inspection Division.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE If
SEWER - SANITAR -. .20C
It
PNER
(Thiswelimn need not be camplctcd litM permit is forone hundred dollars(SI(M)
ter less.)
WATER HEATER W/VFNT/ELECTR
I certify that in the performance of the work far which this permit is issued, l shall
nal employ any penmt in any m o as m became subject In the Wnrkemp
PAID
Compensalionlnwsof Celifomia. Dams
Applicant
WATER SYSTEM/TRHATING
me Receipt#
NOTICE TO APPLICANT: ILufter reeking this Cmifcate of Exemption, you should
become subject m the Wurk,e, Compensation provisions of the Labor Cade, yoo must
NEW RESIDENTIAL PI.MIL. SQ. FT.
TOTAL:
fmthroth comply with such provisions or this permit shall be deemed resulted.
BUILDING F r.
�y
SEISMIC V E
CONSTRUCTION LENDING AGENCY
I hereby affirm Thal there is a construction lending agency for the performance of
the work for which this Permit is issued (See 3097. Cis. CJ
Lend, /, Name
TOTAL:
ELECT FEE
Isomers Address
QTY.
MECHANICAL PERMIT
FEE
PLUMB GFEE
1 certify then I have read this application end shire that the above information is
rect. lugree to comply with old city and county mnllnancee and smtc lawn relaing to
PERMITISSUANCE,
MECHANICAL FEH
buildingnmstm,dierand hereby and ire represemmisesoflhis city luenmr upon the
above- mentioned property for io ,etinn purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
(We) a,. to save, indemnify and keep hamless the City of Cupertino ,grind
m
liabilities.jidgmems,costs. tiespfraesw Ian yweyacerusegainetsaid City
AIR HANDLING UNIT TO 10,000 CFM)
in Inns, .• cor the gr' i¢II y(^i
q�
/}��]�'� 1°
11A01
AIR HANDLING UNIT (OVER 10.M0 CFM)
isTIgnamzc of ffplicarmuTmineurner I Dam
P.XHAUST HOOD(W /DUCq
PAID
HEATING UNIT (TO IW,OfI(I BTU)
Uam 0.meipt#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupant store or handle havadous material
to defired by the Capmino Mumet Code. Chapter 9.12, end the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Code, Section 25532(n):'
yes ❑ 255
VENT'1LATION PAN (SINGLE. RESID)
't
Willthev licare orfaurcbuildin occv
pp g #rotas, equipmenmrdeviceswhich emir
�ezardous air cmtumirants ., by the Bay Area Air Quality Management
)ismicfl
BOILER- COMP(3HPOR 100,00EBTU)
A,SUANCE DATE
N
OF �O
BOILER -COMP (OVER 100,000 BTU)
❑ yea
1 have rwd the hormdaus materials 11.4emems under Chapter 6.95 of the
California Hahh & Safcry Cale, Sections 25505, 25533 and 2 34.1 understand Nat
(I
Cif y ` 1 l9,
l- �7
NEW RESIDENTIAL MECH.—SQ. Flt
if the huilding does no urzently hu nl,t yr nnsibility io notify the
mthe,uof the menu chin rni eofaC ifca of
race
L (/
~C/'��
Occupuncy.
ISSUED BY:
Ow runthorzed gem p to
TOTAL:
OFFICE