27057 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBING- ERCHA IC PERMIT No. 27057
BUILDING DIVISION APPLICATION/PERMIT - Pw,PRO JEMEr,HpNIFIC
BUILDING PRU.IEI;'I'IDENI'IF'1CA'ITUN
BUILDING ADDRI?SS: SANITARY NO. APPLICATION SUB_1MITTAL DATE
caaeexRIv�&tNITJI 10 LO fif
O ERS NAME PHONE" CONT CI'OR'S NAM' EJC NO: Fir CONTROL
1 D.C. 6-Z4 b
ARCHITECT - GINF.ER: LIC NO: ADDRESS: ❑
_ONTAUI: PHONE:
QTY. ELECTRIC PERMIT FEF: BUILDING PERMIT INFO
HLDG ELECT PLUMB MECH
PERMIT ISSUANCE E3 ' ❑ El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
C=Z I herebymffiantbat l am licensed under previsions of Chapter9(commencing with TOR DESCRIPTIO
LL100 full force adefeDivisiont3 of the Business and Professions Code,end my license is in ppNpjS
tCU�
License
nse lass effect.
aZu1 Lironve Class LIf.# UP TO 200 AMPS
m 6 ec Date Contractor 201-1000 AMPS
F^,z ARCHITECT'S DECLARATION OVER 10110 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
,ZOOZ-M Iandcrstmd my Plum shall be used as public retards.
�,YS F uI SIGNS FF FC IUCAL
�yJ Licensed Professional
qyva< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
cdgEU. I hereby affirm that I am exempt from the Contractors Limma Law for the
W 1z-m following mason.(Section 7031.5,Business and I mmssiom Code:Any city or county 'TEMP.METER OR POLE INST.
Jwhich requires u permit m construct,aper;improve,demolish,ni repair any structure
sn>+;� prior to itsissuance,alsorequirestheapplirmtforSuchpermittorileasignedstatement FEWER DEVICES
W S C Oz that he is licensed pursuant to the pro,kiom of the Communities License Lew(Chapter
LLe4. 9(commencing with Section 7")of Division Sof the Business unit Professions Cosi POOL ELECTRIC VALUATION
or he is floambinriand the basis fur thealieged exemption.Any violation of �
r�
WI-Zapplicant Q Section by any applicant for a Permit subjects the applicano a civil Penalty of OUTLETS-SWI'fC1IES-FIXTURES
'IZSnot more than five hundred dollars($500).
❑ I,asowncrefthe properry,onnyemplayeeswith wngesusthcirsolecompmsation, ' EW RESIDENTIAL ELECTR _SQ.FT. STI
RIES 'TYPECONSTRUC'TION
a3— will do the work,and the strumum is not imendedmoffemd furious(See9044
and Professions Code:The Cantrngors License Lew does nal apply to an Ow of
prnpeny whobuilits oTrmpmvas thereon,unit whodocs such work himselfort ghhis \
own employees,provided thatsuch improvementsancom mandedoroffersyo Ie.If, OCC.CROUP RES.UNITS
howeverdhe buildingmimprevemcm is sold within oneyearofcomplveoglheowncr- \ TOTAL: '
builder will hove the burdenol pnovingtho he did not build tri for puBxtse of
le.).
❑ Las uwnernfthe property.amexdusivelycom " 21hceasedconvacto to QT Pt`MBING PERMIT' FEE FLOODZONE APN
construct the pmjact(Sec.'7144,Business a ,Pmfessioas Code)'The Contracto -
LlcenseLnwdcesnotvpplytnunownernf pony who M1ulIdsor improves therean,an MITISS N - -
whnconwcleforsuchprojectswishaeon ectags)licenxdp......
ome Contmc pL'IR -D A VE WATER CA
License Law. (' ) 17EE SUMMARY
❑ 1 am exempt under Sec. - ,B&P 1 is pr th' B CK jLO 'ROTE VICE - OUT FS
SANITARY YN
Owner Date I 5-PLOD ,ROOF, ,CONE. RECEIPTM
WORKMAN COMPENSA'1' NDECLARATI SCITOOh TAX YN
❑ Thereby uffrn ohm lhavcuctnificmc of cn anal selGinsurc,ora it feet REcUirrit
Worken'Compensatinn lnsumncmru cenificd cap hermf(Sa.3g00,Lab J hich FIXTURFS�PCR TRAP PARK FEE Y N
car,ml employee's underthis permit. GAS-fI .SYSTEM-1 INC.4 OUTLETS RECEIPT'p
policy BUILDING DIVISION W ?S
Company GAS G.SYSTEM-OVER 1'LANCHECK FEE❑ Certified copy is hereby fumishrd.
❑ Certified copy is fled with the airy inspection division. 2REASEiINDUSTRL WASTE INTERCEPT OR GRADING FEF?
is
CERTIFICATE OF EXEMPTON FROM WORKER ' GREASETRAP _ SOILS FEE
COMPENSATION INSURANCE
Hniscenianneed not be completed ifthe Permit is harem hundred do ($100) SEWER-SANITARY-STORM RK.200FT'. ENI?RGY PEE
or less.)
I certify that in the pe,finmarreofthe work for which this permit is issued,Is WATER HEATER WNLNTFLECTR 1
not employ any person in tiny manner so as to become subject to the Worked PAID
Compensatioalawsof Califomia, Date WATER SYSTEM?RFATING to keceipt#
O z Applicant -
z�+ C NO TICS TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rCl- became subject to the Worker's Grmpensution previsions of Ne Labor Code,you most
� , forthwith comply with,adt provision,or this pemitshall be deemed rcvaked. BUILDING FEC
C1a rr SEISMIC FEE
F. Q
CONSTRUCTIONisacomLFNDING AGENCY
U Ib U
z Thereby hich'hhenhem is acued(Se 3097,Cis.Cermy for the pedmmmeeof
V O Lffic amsr'k[or which this Permit is issued(See.3lg)],Cis.CJ T'OT'AL: ELECTRIC .0
�r Lendee.None
F' LenJcrs Address Q'PY, MECHANICAL PERMIT FEE PLUMeIN FEE
I a1 certify that I have read this application and scam that the above information is
carom.Ingrce to comply with all city and county ordinances and state laws muting to PERMIT ISSUANCE. MECHANIC it I'M
buildingeonsauction,and hereby authorize representativesufthis city to enter upon the
V above-mentioned property for inspection purposes. ALTHRORADDTOMECIL CONSTRUCT NTAX
(We)agree to save,indemnify and keep harmless the City of Cnpenima against
liabilitiespdgmcnn,costsmdexpenaes which may in any way accmeegalmt said City AIR HANDLING UNIT(101(,000 CFM)
in consega fe#matin of his non it.
Z7 � AIR HANDLING UNIT(OVER IO,OgI CFM)
tamrc of APPlicant/Camrazmr Date EXI IAUSTIIOOD(W(DUCT) PAID
I AZARDOIIS MAT'ER ALS DISCLOSURE: HEATING UNIT(TO 100,000 BTU) Din Receipt#
Will the applicant m future building Occupant some at handle harardous material IIIiATINC UNIT(OVER 100,1100 BTU) L:
as defined by the Cupertino Municipal Code.Chapter 9.12,vad the IIea1N and Solely
Code.Section 25532(v)] -
❑yes 11 No VI?NT'lLA'fION PAN SINGLESINGLERCSIDI
BOILER COMP(JHP Oft IW,000 BTU) - ISS E
Will theapplicantnrfirmrebuildingtwcupantucequipmenmrdeviceswhichemit , p p�
•�ha`'adi us air canemimeox as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) P .4 #
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the haznrbm mamdals nalmo mark under Chapter 6.95 of the SEP '27 1994 '
Celilomia Ileahh&Safety Codc,genions 25505,2553)mJ 25334. I oder icad that
ifthc buildingdoes notcuremly have ammmWhatr is my responsibility m �s�l notify V f
occupant of the requirements which must be met prior m issuance of a Certificate of W �Urtry I11VI
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED B :
OFFICE '