27959 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PIiRMIT NO.
CITY OF CUPERTINO PLUMBING-MECHANIC 1,
nus JjNO DIVISION APPLICATION/PERMIT BUILDING PROJECT IDENTIFICATION 27959
BUILDING/ADDRESS: SANITARY NO. A/PPIUCAT11ONS/kUBMI TALDATE
sL totO S UN11'N IAT# Vc
OWNIiRO AME: PHOyE: CONT 'SN LIC NO: \\\ A.VWWV
N/C CONTROL#
AR ITEC(ENO NEER: LIC NO: AD R al. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. E RIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL _ JOB DFSCRI ION
OWyez I hereby affirm that I sm licensed under provisionsofCbspter9(cotmnencing with (/vl,—�',�,,f�1✓
FOO Section 0000)of Di 3 of the Business and Professions Code,and my license is in PANELS
y�WU full force and eflenvtsan UPT02WAMPS
<< License Class Lic.#
F~N-=z Date a HIB'Eoun to L TI L7' 11. OVER IOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ[?,O dentn shill a od6licrecords. 41Nbi,
LANVOts, 201-I"AWS
OQy-tee ^ a ` SIGNS ELECTRICAL
F Licensed Professions OW ER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
ii0.CC0E. 1 hereby affirm that 1 am exempt from the Commnors License Law for the
co following reason.(Section 0031.5,Business and Professions Code:Anycity orcaunty TEMP.METER OR POLE INST.
4J ON; which rcyuires n Permit to construct,art,improve,demolish,or repair any structure
Y2 prior to its issuance,also requires the applicant for such pemdt m file a signed statement POWER DEVICES
W <O that he is licensed pursunnnolhe Provisions of the Contractors License Law(Chapmf
y Oy. SWIMMING POOL ELECTRIC VALUATION
W 9 that
ingwith ereiromadthe Division Sof the Business end.Any Vons Cale)
m orthm heir L5byayapplimand the perist sujeasegedeaemsom so civil Porosity
of OUTLETS-SWITCHES-FIXTURES
t z,Q Section
metion.56y uundrdd.111a,MIermit subjects the aPPlicanttoacivil perWty of
t marc than f ce hundred Jo11ars(Sapp.
FG NEW RESIDENTIAL FlECIR _SQ.FT. STORIES TYPE CONS'IRUCIION
p
. -me ocheLtxwrk,Mthepsuriatme 0rmyempmyed or ofered frsafeirmle c0m,Business
y3� will dathework,and the he Contractors
License Law
appl(Secy
70,14,Business
and Professions Cafe:The COntherear License oa�such w does not apply to an owner of
ownpropsenywhob.Mviii th.te.thhimomandwh mnotinim oroffeod fms e.If, pCC.GROUP RES.G
NM
improvementsartne intendedoroffend for sale.If,
however,illhav l the burden
ofementis"the did ad
eyem or improve for
purpose
of
the sold TOTAL:
builder will have the burden 0f proving that he did not build or improve far puryou of
u1e')' QTY. PLUMBING PERMIT FEE
wFLOOD ZONE "NN
C] er
I,mownofthepmpeny,am xclusivelyn=tingwiNlicensedc.n m,.
construct the project(Sec.7044,Business co
usiness and professions Cade:)The Contractors
License Luwdoes notupply to on ownerol'property who builds orimprovestheuon,and PERMIT ISSUANCE
wheamtmcts for such projects with asnoractor(s)licensed pursuant to the Contracture
License Law. FN (EALTER-DRAIN&yT-WAT[R A) FEE SUMMARY
❑ I rum exempt under Sec. ,B&P C for this reason OUTSIDE
BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Dam D S-FLOOR,ROOF,AREA,COND. RECLIPTN
WORKMAN COW WSATIONDECLARNG N SCHOOL TAX Y N
❑ Ihmcbyafftrmthmlhaveaart0ateofconutntoxl6in.um,or.certifi ate of �X.fOR -pEg p RECEIPT#
Worked Compensation Irsmance or a certified copy thereof(Sec.3gW,LabC which PARK FEE Y_N
coven nll<mpin.'4. 1 this permit
Policy# BUILDING DIVISIL GAS-FA.SY M-I INC.40UTLETS RDVISION FEES
p
72
CompanyGAS-EA.SYS HEA) PLANCHFE
ECK E
U. C E c pyo ere yfu m
-Je6owed copy is filed with the city inspect ion division. GREASIV1 DUST .WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WO RS' G SOILS FEF.
COMPENSATION'INSURANCE
(This section need not be completed ifthe permit is for nehundrcd tha(SHIP) SEWE - NIT RY-STORM P.A.200FE ENERGY FEE
or less.)
I certify that in the perf0munce of the work for whit this permit is issued,Ishel eggR W/VENT/ELEGTR
not employ stay person in any rammer so ea to becam subject to Ne WorkemPAID
Campcnxtionlxwsof Celifomis. Date SYST MfMEATING Data Receipt#
O Z Applicant
Z NOTICE TO APPLICANT:ILaller making this Cenffcate ofpt cold RESID AL PLMIL SQ.Pf. OTAL:
r V] becomens
subject to the Workers Compensation provisions of the C must
C4
; faMwith comply with such provisions or this parrot shall be domed BUILDING
a [� CONSTRUCTION LENDING AGENCY SEISMIC
(hereby affirm thanthem is o construction lending agency for the perf eaf CLE
D z Q the woh for which this pemdt is i�ed(Sec.3097,Co.CJ
i1 ry Lernder's Name PL EE
t•-' Leaders Address QT MECHANICAL PERMIT ME
0 L) 1 certify that I have read this application end stere that the above information Is MECHA AL
�" a correct lagremocomply with dl<iry and wunry ardittancm end state laws relatingto PERMIT ISSUANCE
czi buildingarostruction,and hereby authorix repmuntntives ofthis city to anneruprt the CONSTRU ON TAX
L) 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
F7
(We)agree to stave,indemnify and keep ss the City of Cupertino against
lminfi'expalls urta,coam and m
M
enywayaccomagainstsaiiCiry AIR HANDLING UNIT(1010,000 CFM)
int eofth wit
/p AIR HANDLING UNIT(OVER I0."CFM)
Simulate of Applicuntlortr Dam 0 EXHAUST HOOD(W/DUCp PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW.OW BTU) ReceiptM
Will the applicuntm future building nccupard.wa or handle hazardous material HG TING UNIT(OVER IW.OW BTU) T
as darned by the Cupertino Municipal Cade,Chapter 9.12,end the Health and Safety
Cak.Section 2553200? VENTILATION FAN(SINGLE RESID)
❑Yee ❑No
ISSPAE DATE
Willtheapplicuntorfuture building occupant useauipmentordeviceswhichemit BOILER-COMPQHPOR IW,W)BTU) ,qqttp
hazardous ser conmorm an s u dermad by the Bay Are.Air Quality Management BOILER-COW(OVER 100,000 BTU) P#`7
District!
❑Yu ❑Na NP.W RESIDENTIAL MECH. SQ.PT.
I have tend the haaallous materials requirement.under Chapter 6.95 of the OR 18
California Health&Safety Code,Sections 25505,25533 end 25534. I understand that /s t
if the building does not currently have a tenant,that it is my responsibility to notify the GI U
occupant of the requirements which must be met prim to issuance of a Certificate of
Occa .acy. LIQ
Owner or amhmimd agent Date TOTAL: ISSUED BY:
OF I