27216 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO x U.DI G-EI.hurRI AL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING,PROJECT IDEN'I'1FICATIDN 27216
BUILDING ADDRESS; I/ /I�/ SANITARY NO. A1PPLICA'11ONSUBMITT LD TE.
(lC Via_Q ' (IQ Ia UNITp /Qi/ LOT It 1 r
O ER NA F.: �/ PHON CONTRACTOR'S�aME: LIC NO: LLL
/ a lora HCNaCO 'q0 "= icw CJ aj er NIC CUNTROLp
lie ARCHI'MC`DENGINF.F.R: LIE NO: ADDRESS: ❑
COECII
W CT. PHONE:
G /1 G L �1/ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INPO
/C er 4ep � �l..p� PERMIT ISSUANCE flLUG- ELECT PLUMB M
LICENSL' CONTRACTOR'SDECLA TION APPLIANCES-RESIDEN IAL V�j�� •IItTO�}fll(DF.SCRIPTIL{F�JO•N
Qwz I hereby affirm that l am licenxd under provismosid Chapinr9(commencing with
,a 00❑ man)of Section]ODivision 3 of the Business and Professions Cade,and my license is in PANELS,tfall finewmad /'7
Fi, LicnseCf.effect. v
Z tY License Class Lic.M UP TO 200 AMPS
m6y Date ComPucesr 201.1010 AMPS
ZprryZ ARCHITECTS DECLARATION OVER IIXIIaAMPS SQ.FT.FLOOR AREA SISQ.FT.
OZ-0 Iunderxtand my plucustard be usedes public records. ���
K 4 t, SIGNS ELECTRICAL
K Licensed Professional
tv OWNER-BUILDER C.BourON SPECIAL CIRCUIT/MISC.
OLF I hereby affirm that I an exempt from the Commcmrs License 1nw for the !1'11
30.m followingmason.(Section]031.5,Business and Professions Code:My city or county TEMP.METER OR POLE INST. �v/(C.J/
�; which inquires a Permit to c.nnrvet,eneq improve,demolish,or repair any structure
�;!(}� priuno its issuance,also requires the applicant forsuch permit to rite o signed statement POWER DEVICES
a p that he is licensed pursuant to the provisions of the Contras.s License Low(Chapter
tikL�o�' 9)commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is exempt therefrom and the basis for alleged exemption.Any violation of /s/ L �S� ryv
a
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES C_7/ �+ O[/v /a
S nm mI.mown fism rofthedrddol.mmyemq. NEW RFSIDENTIALELECIR _SQ.PP.
N STORIES TYPE CONS TRUMON
❑ othe wrk,ond[he openy,e is nut
compensation,
y,q� wllldmhewam,and the Mae
Cis mutt.i Luanne Law
b act (ply 1..Business
amJ Professions lds orr The Cnntrudors License Law does not apply to an owner of
is
propertywhobuildsorimprovesth improvements
and who doessuchworkhimself aldwugh his
wnemployecs,provitled mhetmch impmvemente eenot intendcdorofferedforsale.If, 142 0&
OCC.GROUP
RHS.UNITS
however.the building or improvement is sold within oneyear of Lumplation,the owner- TOTAL:
0;R aa
builder will have the burden of proving that he did not build or improve for puryose of
sale.). TY, PLUMBINGPERMIT FEE �L�OD ZONE LAPN
❑ Las owner offbproject
(Sec.70,1. Business and rofessio with lie<)The Corecmrsto Q J _
construct she project(Sm.to an
Business and ywholiora Code)The Communist's
who carinexis
Lawdfrsuc applypjects owncrofpmpcnywhosed paorimt tothehereon,and PERMIT ISSUANCE
Liscme Law. ALTER
such projects with uconwmor(n)IicenxJ punuenuothe Comrvcmr's ALTER-DRAIN&VENT-WATER EA
Lignac Law. ( ) FEE SUMMARY
❑ 1 em exempt unJer Sec. ,B&P C for Jtis reason BACK R.O W PROTECT.DEVICE. SANITARY Y DL N
Owner Date RECEIPTp
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND. SCHOOLTAX YN
❑ I herehyaffrtm that l have a cenificamoftoment oself-insure,oracenificamof RECEIPTp
Workers'Com FIXTURES-PER TRAP
pe,ce tnderdeBceora certified copy thereof(Sce.3g00,Inb CJ which PARK FEE Y N
colors all employee's under this permit. GAS-PA.SYSTGM-1 INC.4 OUTLET'S RD 'M
Policy p BUILDING DIVISION PEES
Company GAS-EA.SYSTEM-OVER4(EA) PIANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cethfical copy is filed with the city inspection division. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tbissection need not be completed ifthe permit is for one hundred dollmx(SI00) SEWER-SANITARY-STORM M.200F1'. ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,)shall WATER HEATER W/VENT/ELECIR
not employ any person in any m.nne an as at become subject mo the Workers' PAID
Compensation L.ws.f Culifnmio Date WATER SYSTEMMEATING Uam Receipts
z'OApplicant 0 NOTICETO APPLICANT.If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB.—SQ.FT. TOTAL:
F V) becomesubjemo the Worker's Compensation provisions ofthe Labor Code,you must
� ; fntle ithcomply with such provisions or this permit shall be deemed revoked. BUILDING FEE J 7
G [a CONSTRUCTION LENDING AGENCY SEISMIC FEE 41 . 70
z I hereby vf6mr that there is a construction lending agency for the pe rfomwnce of
U Q the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lender's Name
O PLUMBING FEE F Under Add.. QTY. MECHANICAL PERMIT FEE
U 1 cenify that 1 have read this application and State that the above information is
W MECHANICAL.FEL
coram. legrs to comply with all city and county nNivnttsanJ pate laws relating to PERMIT ISSUANCE
�-"
IA buildingcons0uction,and hembyauNome repreventativesofmhis city tacmeraponmbe 7 CONSTRUCTION TAX s
U obion
ovememcd pmpeny for inspection purposes. ALTERORADDTOMECH.
.^. (We).gree to save,indemnify and keep harmless the City of Cupertino against —
liabilities,judgment,coms.ndexpemses which may in any wayaccmeagaiastasid City AIR HANDLING UNIT LTO IQ00n CFM)
infthe granting ofthis permit,
co fL4 � , `1
F'`1 AIR HANDLING UNIT(OVER I0,000 CFM)
Signature of Applicun ont ter II Date EXHAUSTHOOD(WMUCI}
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000 BTU) Dam Receipt
Will the applicant Mature building occupant Chapter
apstore of and to hazardousmmmal HEATING UNIT(OVER 100,000 BTU) TOTAL:
C c.Sed by the Cuperino Municipal Code,Chapter 9.12,and the HmhM1 and Safety
CrNe,Section 25532(e)l
0Ycs 11 No VENT NATION FAN(SINGLE RFSID) Q
Will thea licaromfuture buildin occu and ux BOILER-COMP(3HP OR 100,001)BTU) ISS NCEDATE
pp g p equipment Quality Management D
District?
issrdous air comnrrdnanm as defined by he Bay Area Air Quality Management BOILER-COMP(OVER Ifp,(pO BTU)
Dial e J
❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FT. A,'I yq ,a�
I have read the haaardous materials requirements under Chapter 6.95 of the (� YYYY ro i / (I['
Cilie buil Health Ac of cur CWyhavea tenanns t,
it is and responsibility
1undersmnd that oil Y u/- r J
if the building Jces not currently have a mnam,that it is my rsuance dila tnotify of {VIa/Y(Iy11/r
occupant of the mquircmems which mus be ma prior to issuance of a Certificate of
Occupancy.
Owner or amhodred ager Date TOTAL: ISSUED BY.
OFFICE