27831 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .RiIs..EEECIfRICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECIIAN7ICAL 1
NUILDINf.DIVISION I101(DING PROJECT I HEN'1'IFICATION
BUILDING ADDRESS: j/�� .,{. C / SANITARY NO. APPLICATIONSUHMG7ALDATF.
va 7V/CL I Cr o • ihD UNIT# )0�GYn —J.G.OT# os< C2
13NS PHONE: CONTRALTO NAME: LIC NO: N/C CONTROLp
i O Bs
ARCHITEUTAiNGINEER: LIC ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG_ ELECT PLUM@ MECFk
B�+ PERMIT ISSUANCE L�BJ I#aLl� Y�Ys� 1pOl�
LICENSE ONTIR R'S DECLARATION APPLIANCES-RESIDENTIAL 108 DESCRIPTION
Matz I hereby uffirn that l am licensed underprovisionsof Chapter9(commencing with
IA00 Section]OW)of Division Sof the Business and Professions Code,and my license is in PANELS
,Wv5 full force and effect.
F¢m License Class Lic.# UPT0200AMPS V���II��JJJJ
m a o. Duro Connector 201-LBW AMPS SQ.FT.FLOOR AREA 8/SQ.FT.
Z OyK ARCHITELTS DECLARATION OVER 10m AMPS
Z 1 understand my plans shall be,used as public records.
SIGNS �� J0
E.LECDUCAL
yy -� Licensed Professional
C Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
iW4a(�0aF I hereby affirm that 1 am exempt from Ne Contractor's License Low for the
W�Oy following reason.(Section 703L5,Business end Professions Cada.Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alar,improve,demolish,of capain any swctuse
prior o its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
W pp that he is licensed pursuant to the provisions ofthe Contractora License Law(Chapter
a p�' 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION �a/s
—a
or h7031.5 by myapfromunfor a d the foxis Permit
subjects
is the exemant to siviny 1pnalty of OUTLETS-SWITCHES-FIXTURES / f// �(�O. L(/
not
than five
hundred
doltrs($50rmitmbjmts the applicannoacivilpenWyof (� (� e
not more Nan five hundred dollars(Sem). NEW RESIDENTIAL ELEM S .FT.
❑ I,osownendthcpmpeny,ormyemplmyeeswith wages astheirsoleconFam tion, Q STORIES TYPE CONSTRUCTION
d22 will do hawork,and the structure isnot intended proffered fnrsale(Sce 9044,Business
and Professions Code:The Contractor's License law does not apply m an owner of
propenywhobuildscrimprovesthereon,and whodoes such workhircau forthrough his
ownemployms,provided that such impromencateam not intendclorofferead forsale.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yeurofesmpletion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of 00
sale.).
❑ I,asownerofihepmpeny,amexclusivelycontr tingwiNlicensedcontr wmto QTY. PLUMBINGPERMIT FEE OODZONE APN
conswct the project(Sce.]044,Business and Professions Code:)The Contractors PERMIT ISSUANCE'
tr
License Law does not apply m m owner ,of property who builds m improves thereon,and
who contracts forsuch projects with aconactor(s)licensed pursaem mine Conaaclor's
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C fm Nis mown BACK FLOW PROTECT.DEVICE SI
S YN
Owner Data DRAINS-FLOORNOOFARFACONDRECEIPTY
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL YN
EIIherebyeffirmlhmlhaveacenificmeofco ttoazlf-insurc,maaniriateof H%TURPS-PFR TRAP RECEIPT#
Wmkers'Compensation lnsurane,orvcmificd copy Nermf(Sce.38m,Lab C.)which PARK FEE Y N
covers all employee's under this t RECEIPTp
J Permit, GAS-EA.SYSTEM-1 INC.4 OUTLETS
Policy q BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FIE O
❑ CeniRW copy is hereby famished.
❑ CeniBW copyu GlM with Ne city irrspectimn division. OREASERNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Itis sectioammil oath completed if Ne permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM FA.200FT. ENERGY FEE
or tem.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
hour employ any person in any manner so as to become subject to the Workers' PAID
Compensationlawsof Celifomia. Date WATER SYSTEMITRF.ATING Date Receipt#
Z Applicant
Z� 0 NOTICE TO APPLICANT:If,after making this Cerufiate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
i—I an become subject o the Worker's Compensation Provisions of the Labor Code,you must BUILDING FEE
�i forthwith comply with such powisiam or this pandit shall h dmmed revoked.
0. (] CONSTRUCTION LENDING AGENCY SEISMIC FEE / X.
7D
1 hereby affirm that there is a construction leading agency for the performance of
U O the work for which this permit is itma i(Sm.30TOTAL: F.LRCIRIC FEE 99,Civ.C.) 6 y# 813
Iw•raera Nome �/ G
0U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME 67• O�
U 1 certify that 1 have rad this application and state that Ne above information is MECIIANICAL FF.EG
correct.l agree m comply with d all city ancounty orainanms and state laws relating to PERMIT ISSUANCE 6 y 03
n
y buildingeommuction,and hereby authoria,maresentativesofthis city to enter upon the CONSTRUCfIONTAX
U 7 above-mentioned pmpcny for inspection purposes. ALTER OR ADD TO MECIL d
G (We)agree to save,indemnify and kap hornless the City of Cupertino against �—
liebilities,judgments,mats and expert.which may in any way accmeagamst said City AIR HANDLING UNIT TO 10.000 CFM) 1)717LOP
in con scat f the granting of this permit.
AIR HANDLING UNIT(OVER IO,mO CFMI Ir
Si fum of ApplicardlContr9clear p6I Data EXHAUST HOOD(W/DUCO PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO Hat"BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER Im,OW BTUTOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety _
Code.Section 25532(0)? VENTILATION FAN(SINGLE RFSID) �0
78-
❑Yea ❑No 11����
BOILER-COW QHP OR IMM BTU) Ir'$LAAN ATE
Will[he epplicunlor fmwrehuildingoecupum useequipmentordevic<swhich emit UU Ad
hazardous air conuuninonts as defined by the Bay Area Air Quality Management BOILER-COW(OVER IW,"BTU)
District? ESMAR 29 nn
❑Yes ❑No NEW RIDENTIAL MECH. SQ.FT. 199
I have mod the haamdaus materials requirements under Chapter 6.95 of the 'rill Y Ur
Califomia Health&Sufety Code.Sections 25505,25533 and 25534. L onderstond Nat UUrkFf 1
exthebuilding doesnotcurrentlyich ulactam,rheo is mysuanceibllityenotify Ne
oecupwt of Ne requirements which must h met prior m issuance of a Certificate of �s�
Occupancy. 1
Owner our malummd agent Date TOTAL: ISSUED BY:
OFFICE