27602 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOILDIN -ELEU'PRI AI. PERMITNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. 27602
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 11 '' SANITARY NO. APPLICCATVON SUBMI'ITAI.DATE
V V OI UNITN LOTH I � �
OWNERS N ME: PHONE: CONTRACTORS NA P.: �� '-'C/0: N/C CONTROL
ARCHITECfdiNGINEER: LIC NO: A ESS: `` 3 E]4 ata & 2 CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUM FkL:CH
PERMIT ISSUANCE [I
LICENSED CONIiunder R'SDnsofR ter9ION APPLIANCES-RESIDENTIAL J�ESCRI ION q
0,4Z l hereby 7oom ffnm ison.hat I amt the th un ss land isiomaimas ode and my It..g s in
�VO[OFI[�,, Bill ficritud of D�iyvision3 nllhe Business and Rvfessiore Code.and mylicense is in PANELS
FF Ztu Liciense China effe .- ` Lit.N— G . ` ,rw
�$�3l� UPT0200AMPS 1�. 1X�i`L
N7y Dare Contractor 201-1000 AMPS
ZONZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA S/SQ,IT.
OZ-0 I understand my plans shall M used a public meals.
Py W SIGNS ELECTRICAL
9 Licen ed Professional
OWNER-BUILDER DECLARATION ON SPECIAL CIHCUIT/MISC.
°'OyF 1 ng ammo tion 1 am exempt from live Gonion'e:Any law for the
Som following pima (Section'/031.5,Busies and Professions Code:Any city or county TEMP.MET[R OR POLE INST.
Ls.'y5 prirM1 rcyuircsnpermit recores the plat improve,demolish.or repair any structure
f N7 good
he I.licensed pnlsouramestheeisions tfor,heC permit LicnseLaJ staw atement POWER DEVICES - '
y�jK�iQpK 9 h,manarsom,with Se ammNe Provisions coup. .1', camsLicenseladcami doter
aX❑ou. 9(wmmeis exemitM1 Seafrom adthe Division the ee 'ncssmnd.Any violation
ona Cal e) SWIMMING POOL ELECTRIC VALUATION
W_y Sectioorthat n
131.5 by myappmmat f the baspermit subj Iegem mption.ici,il proh,of OUTLETS-SWITCHES-FIXTURES
ZG Senione than vy anydreddollforapermit snbj ache appl antmocivil penehy of
� � no,arae NanfvcmapmparY.ms(5500). NEWRESIDENTIALELECR 5 .FT.
❑ I,axownanfohepmpeny,ormyempiny wish wegesusthe into wmpmral nn, _SQ.FT. TYPECONSTRUCTION
L will do the work,mdthe stmnure isnot loon dnrafferdfarsJel 7044,13miness
and Professions Code:'ILe Contractor's Luse Law does not app to an owner of
progeny whohuildsorimpowee Nercoq dwhodnenauc work bias fur lhrongh his
employees,providedshat such imp, ementa=m dedor fe fondle.If. I OCC.GROUP RFS.UNITS
however.the builAing nrimpmvemenY soldwit 'a, c rigPPi///bbb��ho theowner- TOTAL:
builder will have the burden rfprov' ,that hedi fid orio , Its uHcseof
aaleJ. 1 QTY, PLUMBING PERMIT FEE WOOD ZONE APN
❑ I,ns nwneredthe Amgen exdu' nmruning wit kerne contracsom to
construct the project IS u s d Prom
Fruits not to Cmdracrs PERMIT ISSUANCE /
License Lawdo ormitppl3 o property wind rirap vuthereun,and
whnmmm�
csfns orsuchpmje switha car ice instant oche Contractors
License law. ALTER (IA) FEE SUMMARY
❑ I tan exempt under Scc. ,R P C for this msson BACK FLOW PROMCT.DEVICE UT.IDI.F.
SANITARY Y N
Owner p RECEIPT ts
DRAINS-FLOOR,ROOF.AREA,GOND.
WORKMANC PIiNftidem UECLA TION SCIIOOLTAX Y N
• ❑ Ih-Ciauarentnlemo a ifiaaeedicopennose Sec.SRL.Lou .)which FI%NR&S-PFR TRAP RECF:IPI'N
Wohen'Compenserinn lmurancen ttrtifiedwpytherc (Sw.JRW,Leh C.)which PARK FEE YN
vers ell emplyype's ncr In r GAS-EA.SYSTEM-1 INC.4 OUTLETS RF.CIi1PTN
Company
r/V BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifrul copy is licmby filedwurnls ed.
❑ Certified copy is fled with Ne city ins n division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CF,RTIIICAW,.OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS IME
COMPENSATION INSURANCE
(This section need not he completed ifthe Permit is future hundred dollars($100) SEWER-SANITARY-STORM Fi.20111T. ENERGY FEE
nr less.)
I cenifythat in Ne pedamndre of The workfar whichthis permit is issued.Is hall WATER HEATER WNUNT(ELECI'R
nos employ any person in any moaner w az to become subject to the Workers' PAID
Z Compensmionlawsnf Califnmia. Date WATER SYSTEM/PREATING Dme ceiptW
Applicant
Z0 NOTICE'1'OAPPLICANT:IILaOer ranking this Cenifcate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
l-+ loO becomesuhject to the Worker's Compensation provisons ufohe Labor Code,you..in
!ai
forthwith comply with such prnvisions colas Permit shall M deemed revoked. BUILDING
pw., Ca CONSTRUCTION LENDING AGENCY SETS
5 z I hereby uffinn good here is a construction lending agency furtive performance of
U O the work for which this permit is issued(Sec.3091,Civ.CJ , ELF.
(L P Lender,Nome
Q U lender's Address QTY, MECHANICAL PERMIT FEE PLUMBING ME
U I certify that I have rend this application and some Nat the above information is
acmrccv legrcc mcnmplywithall city end county nrdinananonJ satelows rclming so PERMIT ISSUANCE MECHANICAL .E
_ ,0, building construction,and hercbymalanu,epmsenutivesaf this city to enter donativeCONSTRU NTA%
U Z ab ve-mentioned profanity for inspection poses, ALTER OR ADD TO MECI I.
(We)agree to sour.indemnify and kttp banaless she City of Cupcnino against
Iiabilities,judgmenu,cosn and expenseswhich may in any way acermagainstsaid City AIR HANDLING UNIT(TO ig(XlO CIM)
in conmquyQ.,if hcgru t. /,-s-9r
AIR HANDLING UNIT LOVER 10,000 CPM)
4-, mre of Applicont/Cumrnctor Date F.XIIAUST HOOD fW/DUCT) EAUD
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Dam Receipt
Will the eppliewd or future huilding nccupurn stare or handle hazardous material HEATING UNIT TOYER 100,(80 BTU) TOTAL:
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Ilenith and Safety
Cale,$CCll 25532(nJ
El :'Yes 11 No VENTILATION PAN(SINGLE RESID)
❑
Wusaiithepoulannats as building occupantuse Area
ualityc Management BOILER-COME(311P OR 100,0011 BTU) ISSUA ATE
• hazardous air cnmanrinunts as defined by the Bey Arca Air Quality Mwagement
DiaVicll BOILER-COMP(OVER H)0,000000 BTU)
Cl Yes 0N NF.W RESIDENTIAL MF.CH. SQ.IT. n
I have read the horrendous materials requimmcnts under Chapter 6.95 of Ne t
California Health @ Safry Cale.Sections 25505,25533 and 25574. l understand shat
ifthe building docs notcumendybnve u tenant,that it is my mspansibility roundly the
uaupanl of the requirements which must be met prior m issuance of u Cmificute of
Occupancy.
Owner.,authodzed agent Dam I ISSUED BY: _
OFFICE