27636 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUP6RTIN0 n ILDING.BLEL RICAI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27636
BUILDING DIVISION BUHAHNG PROJECTIDENTIFICA'1'If3N
BUILDING ADDRESS: (� SANTI'ARYNO. APPLICA'I ION SUBMIITALDA'1E
10 +60 E+0keS RV e / UNIT. LOT# s
OF:RS NAME:ii PIIONE: ��//7 �/y CONT'RACTOR'S NAME: LIC NO:
1 1 1 C Uy1 Y/-1 { I N/C CONTROL#
III ECT/IiNGINHER: - LIC NO: ADDRESS:' ❑
TACT: PHONE: BUILDING PERMITINFO
Q'I'Y. Iil,liCPftIC PF,ftM1fll' FEF � �C1�
G' LCF,`— P UMB ECH
•
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RISIDWPIAL
C1=z I hereby affirm mal l am licensed under provisionsol'Chapme9(commencing with
Ic00 Section?000)of DavisIon 3 of the Business and Professions Cale,and my license is in PANELS
y�E+E fail force land effect. 11P TO 200 AMPS
o<ce Dam nt
Coractor IDI-I"AMT'S
ZOnoi
yZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA E/SQ.FT.
CZ-0 I unrsta
dend my plans shall be marina public records.
r'4 SIGNS ELECTRICAL
JiN Licensed l'rnfessa...I
OWNER-exempt 1iR❑EC Contractor's
SPECIAL CIRCIII'I'/MISC.
°QOp,U I hereby affirm that 1 nm exempt front the Craton Co License Low for the -
1 Sao fallowing mason.(Section TB3L5,Boniness and Professions Cade:Any city or county TEMP.METER OR POLE INS(.
F�'ON a which requires u permit to convect,eller,improve,demolish,or inp any manure
KM}m prior to its i...ance,also requires the optician for such permit o file a signed statement POWER DEVICES
❑C40 Ilia,he is licensed pursuanuo the provisionof be Connector's License Law(Chapter
p•�o8' 9(nnnnwncan,with Section?(00)HIDivision 3.fthe Raxinexsand Professions Cute) SWIMMING POOL ELECTRIC VALUATION
Wmy or that he is exempt therefrom and the basis for Ilia alleged exemption.Anyviolationof OUTLETSSWITCHEBFI%TURNS
I—Z_Q Section 701.5 by any applicant for a permit&objets me applicant m a civil penally of - - CSW
not more than five hundred dollars(5500). NLW RESIDIiNT1AL ELECIR _SQ.FT.I p ❑ 1,asowneroftheproperty,ormyemploymswithwagesastheirsolecompensmion, STORIES NPI?CONSTRUCTION
y will do lbsuiumend@'I ImnamasnmxLio, ,c La a does x apply
of
anJ Professions Cade:'I'bu Comrxmrs License Law does nm apply to an owner of '
property whobtildsmimprnvesmuratuand whidoe,imib work himself0nhamgb lits - OCC.GROUP RIS.UNITS
wite er,the
provided Netsuchimprovementsarenotym,o o mofferedfoesale.IL
huwe eq ill have the
burden
of pTem is hat he did
year or improve
omm a for purpose
of _Vol;
builder will have Ibe burden of proving that he did not build or improve for puepse of
W
it, ra[ate propeny.nm excbtxively n�mrmlangwim liwnxul conannnrsm QTY. PLUMBING I'ERMI'f - FE8 n.DOD ZONE APH
nstm. 'c pmjocl(Sec,7( ,Business end Profesximi,Cadet)The Contractor's
kricenseLawdoesten apply manownerofpropony who buildsmimpmves thereon,and PERMIT ISSUANCE
whoc.mrsCls for such projectswith a comracmr(s)licensed pursuant o the Contrunols
License Law. ALTER
VENT-WATER(EA) PEE SUMMARY
❑ 1 ant exempt under See. ,B&PC for this mason ACK FLOW PROTECT. V ICE . UL FEE.
SANITARY YN
Owner Dots RECEIPT#
ORNNS-ILOOR,ROOF,AR ,GOND.
WORKMAN COMPFNSA'1'ION DECLARATION SCHOOLTAX N
❑ Thereby affirm mm lhave acenificete pf consenu.elf-insum,maceni mof 19XTURFS-PER TRAP F.CEIYTp
Worken'Compensation insurance or a cerified copy thereof(Sec.3800, .)which PARK FEE N
j covers all employee's under this permit. GAS- A.SYSTEM-IINC.401II1.B S � El #
Policy# _ )l to :3S -
Company - ,SYSTEM-OVER 4 PEA) PLANCHP. .F.
❑ Cenifiede.pyisheeehy fumisheJ. 'a—,❑ CenificJ copy is fled with Ne ciry inspeainn Division S 1NDUSTRL i' STE INTER EPfOR
CERTIFICATE OF E%EMPI ION PRO ORKERS' GREASE RA
COMPENSA'PION INSURA This section need not be completed if the palinal' for Crone hunJr (EI(0) SP, .R- NITAR -STORM .A.2 Ff. ENERGY,7'r
mless.)
I cenify that in the perLnmance of be wad foe ichlhispemlilisis ed, &hall AER HEATER WN' /ELECfR
nm employ any person in ony manner an as 1.be m subject m th rkcrs' PAID
C.mpenso,inn Laws of Culif.mix. Date - WATER SYSTIiM EATING ate Receipt#
Q Z Applicant -
Z 0 NOTICE TO APPLICANT:I L after makingthis Cenatica of Exemption,you should NEW REST ;N'IIAL PLMB. SQ.IT. TOTAL:
bxame object the Worker s Compensation pmvisionp he Labor .Code,you nun BUILDINGF
forthwith comply with such provisions of this permit shall mod revoked.
Lia .. SEISMIC ITE
lis. [a CONS'fRI1C1'ION LENDING AGENC
L,^ Thereby affirm Ilial there iseconstruction lending agency lb eperfnmmnce of
U O the work for which this .it is issued(Sca 3097,Civ.CJ L. ELECTRIC T.
Lenders Name
F Lenders Addmas QTY. MECIIANICALPERMIT FEC PLUMBING
1„) I ocrify that I have mad This application and state drat the above information is
>1 Ila correct.l agree to comply with all city and County ordinancesand state lows relating,. PERMIT ISSUANCE MECHANICAL E
huildingcnnsvunion,and hereby ammo,! ,maentafves alibis ciry,.emerupnn the
U Z above-mentioned rt for inspection ALTER OR ADD TO MECH, CONS'I'RIJCTIO TAX
property Pec peeps!
I Wc)agree m save,indemnify and keep harmless the City of Cuperino against
liabilities,judgments,costs ander n swhmh may in any way accmeagainsl said City AIR HANDLING UNIT(10 10,000 CPM)
in consequence of the gmmang tis pe it, C
AIR IIANDLING UNIT(OVER 10,000 CPM)
gnammof ApplicanUCmomc Date / HXHAUSTHOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS D SCL URE HEATING UNIT(TO 100,600 BTU) Date Receipt#
Willme applicamor future building oaupant sat handle haurdmi.mamrial 1117ATING UNPP(OVER IOLPXM BTU) O'
us deftncd by the Cupertino Mani ,.1 Code.Chapter 9.12,an I the H.Ilh and Safety
Code,Sectio 25532(a)? VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
Will the uombamo e,as refining by the Bay Am.Air anality Management BOILER-COMP(3HP OR IW,(00 BTU) I UANCE DATE
District?
air cmntaminams as Defined 6y the Hay Area Air Quality Monagcment BOILER-COMP(OVER IOQIXO BTI!)
District?
❑Yes C No NEW RESIDENTIAL MECH.—SQ,IrT. h
I have readra
.the materials requirements under Chapter 6.95 of the PAID
I
.— Califnmiulleahh&Safety Cede,Sep,ioms25505,25533and25534. ltadersmndthat Face.
if the hooding does not currently have a tenant.that it is my responsibility to notify the o B / Q
ecti, I of the requirements which mus,to met prior to is.vuunoe of a Cenifinno of
Occupancy.
Owner or authmaeJ agent Data T( ISSUED
OFFICE /