27921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOR.15TNC.hO.1..UrRTCAL PERMIT NO. a� ^ w w
% 192
APPLICATION/PERMIT PLUMBING-MECHANICAL. L
BUILDING DIVISION BUILDING.PRO.IECTIDENTIFIC'A'I'ION
p UILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I V�s \/� �.! 1 LOTH
OWNERSNAME: PHONE: e5NI RAC'I OR'S NAM F. LIC NO: l
GO_ ) N/C CON'I'Bid,#
NCIII'TECT/ENGINEIiR: LIC NO: llli� /4
P 'b: / /e -f— S
'ONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
ELECT PLUMB MECH
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RBSIDF.M'IAL - - JOB DESCR ION
zy�y Thereby afpnm
LICENSED
OR'SsDECL DECLARATION
gwith CVs LLL�N�I
FOO Swalnn]00o)of Division 3ofmc Business end Professions Cndgand my license is in PANELS
�U� fu 11 force and effect. L
P
'ZyW License Class Lic.p UPT02013AMPS
in 6 ais, Dac Contmcmr 201-1000 AMPS
hy2, ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ,FT.
OZ y❑ I understand my plans shall be used as public records. OVER IOW AMPS
F y F-; SIGNS ELECTRICAL
Qx5,..1 Licensed Professional
Z,,ie OWNER-RIl11DER DECLARATION SPECIAL CIRCUIT/MISC.
OaU I hereby affirm that 1 um exempt from the Contractor's License Law for the
W1 :p.y following reason.(Section 7031,5.Business and Professions Code:Any city or county TEMP.METER OR POLE INET.
��� wblch r{alms a s m it to ennstmct,alae.improve,drandi h,er repair any structuro
Y� print to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
the,he is licensed punaa:t In the provisions of the Contractor's License Low(Chapter
4(commencing with Section](10(y)of Division 3 ofthe Business end Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_,� must,he7031.5 by uhcrefromand Ne Permit subjects
thedexemant to civil
of OUTLETS-SWITCHES-FIXTURES / (�Y/
f-ZQ Scalar]than byany
ive applicant subjwnthe applicennoecivilpenalty of !�"`/
WSO tmorethan rofthe ter nyl,ormyears m). NEW RESIDENTIALELECTR SQ.FT. STORIES 'TYPE CONSTRUCTION
N.'�'o n❑ oche wnemfMeestrucy,ormyemployed mothered
(or sale
compensation,
a3o0 will do lesions and the he structure License
not apply
to an Business
and professions hours.,
The Contractor's License Law docs not apply m an owner of
own emp,auyloyees,
pdnvidedbutrovesdi impr and who ammo such work oroff remhrough his
own empinyew,providd lhaa sucbimprovemenaurenot intumddorofferedfor sale.If, I OCC.OROUP RIES.UNITS
however,the building orimprovenient is sold within one yew of completion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
' ❑ I,as mwnermnhepmpeny.ameadusivelycontmningwith licensed contracmnm QTY. PLUMBING PERMIT PEE FLOOD LONE MN
ammuct the project(See ]two,Business and Professions Cale:)no Corerecaors
License Law does not applyto anownerofproperly whobuilds or improves Hereon,and PERMIT ISSUANCE
whocon metsfor such projects with aconaractords)licensed pursuant to the Contractors
License Law. ALTER-DRAIN&VENT-WATER HA) FEE SUMMARY
❑ 1 it.exempt under Sec. ,I&P C for this reason PACK FLOW PROTECT,DHVICP. - OUTSIDE IiL.
AN I'1'A_RY Y N
Owner t Daae _ RECEIITp
DRAINS-FLOOR,NOOP,AREA,COND.
'WORKMAN COMPENSATION DECLARATION SCHO L. Y
Cl therebynffinnthntlhaveceoricmifi con thmof(insure,ora r<C.)chiof FIXTURES-PER TRAP RECEIPI'p
Wmken'Compensatinninsunnce orecenifid copy therenf(Sec.38W,i�b C.)which PARK IIiE YN
rover ell employee's undcnhis permif GAS-FA.SYSTEM-I INCA OUTLETS RECEIPT X
Policy MBUILDING DIVISION ITIS
Company a GAS-EA.SYSTEM-OVER 4(CA) P GIIECK FEE
❑ Cionifiedwpyishershyfumishal.
[I Certified copy is fled with the city inspection division. GREASFjINDUSTRL WAS'I'B INTERCEPTOR GRADING ITE -
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP 50114 FEE
COMPENSATION INSURANCE
('Ilia section need not becompleled ifthe permit is foronehundrd dollars($100) SEWER-SANITARY-STORM FA.2W171T. ENERGY PER
in leu.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENDF.LECTR
not employ any perm: in any manner an as to become subject to the Workni PAID
Compesainionlswsof California. Data WATER SYSTEM)TRPA'[ING Date Receipt .
Z Applicant -
Z 0. NOTICE TO APPLICANT:If.after making this Cenificem of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL-:
(~ Val hecomc subject to the Worker's Compensationpmoisimeof the Lahr CWe,you must
1 fonhwith comply with such provisions or this permit shall he deemed revoked. - BUILDING Ilii
6Wi Q CONSTRUCTION LENDING AGENCY SEISMIC THE
Z Ihereby eMo.met there is a construction lending agency fonbe performance of
U the work far whichhis permit is issud(Sic.3090,Civ.C.) TOTAL.: ELECTRIC FIDE
I.cadds Name 0 PLUMBING IEE F Crudit's Address QTY. MECIIANICALPERMIT FEE
U 1 certify mor I have red this application and,t.tc that the above information is
>" W cnect. la,metocompiywithillcityandcountywiirwasseandetetelinsincatingm PERMIT ISSUANCE MECHANICAL.TEF.
F^ ,,I huilma,eonmvuctionand hereh,malmirize represenmtiveso!this city menterupomic CONSTRUCTION TAX
U above mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree uit o, adct999��arfy unci k OF harmless the City op'Cupertino against
lithi brwa,judgnyR aero lyCxpensesw ' may in any way accrue againstsaid City AIR HANDLING UNH'('I'010,WO CFM)
el i*,jen C egr ar(9 of hie
AIR HANDLING UNIT(OVER 10,000 CFM)
'ignam of ,Con It, - Dam EXHAUST HOOD(W/DUCM PAID
H RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt s
Willthe applicant or Mobuildingoccupantstorem and th haealthamaterial
¢s defined by me Cupeninn MunicipmlCWe,CM1npmr 9.12,and the Health and Safety HEATING UNIT(OVER I00,00)BTU)
Cade,Swain:25532(a)]
1:1 Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 101,000 RTU) #SSUANCE DATE
Willmeapplicantorfuaumbuildingoccupntuuequipmemordevimswhichemit 1,D
hammmis alt commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IW.000 BTU) �^
Distric0 R d
❑Yes ❑No-4 NEW RESIDENTIAL,MECH. SQ.FIL
I have read she hzurduus materials requirements under Chapter 6.95 of the y/�(/h` 9gs
Cuhe building
do&Sofmy Cale,Sections 25505,25533 wed 25534. I undersand that A.
lithe building rices not m haven tenant,that it is my responsibility io notify the
wupant of the requirements
n.v w which most be met prior to iuuunw of u CeniOretc of /��� Nn
unc _
(kcupy. 1r{/JyJ[`�J//x�\h
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE-