27828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDI ELECIKI AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL O n O
BUILDING.DIVISION BUILDING PROIF.CF UMN'ITER ITERATION 27828 G 8 2 8
BUILDING ADDRESS: /11/ //�'� SANITARY NO. APPLICATION SUBMITTAL DATE
7 is to / UNIT# I /� LOT# a 3
O CRS MF: PITON CONTRACTOR'5 NA E: LIC NO: N/C CONTROL#
mf 'an o y� SS ton r
•ARCHIIECP/ENGINF.ER: LIC NO: ADDRESS: ❑
CONTACT': PHONE: BUILDING PERMIT INFO
QTY. IiLECTRIC PERMIT FEE
BI.DG' F:L PLUMB MECIJ
I e �r PERMIT ISSUANCE IrrbK-/ X .Ir}Opl(
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
QWz LOB DESCRIPTION
(hereby affirm lhmlvm licenses)underprovisinnsof Chapter9(commencing wish
to 00 Sectiorve and e f Division Jaffna Business and Professions Code,antl my licrnse is in PANELS
K W t full force and-tree.
FZlau License Class Lic,p UPT02W AMPS
m6so Date Connector 201-1000 AMPS
ZOyZ ARCHITECI'SDECLARATION OVER IOW AMPS SQ,FT.FLOOR AREA S/SQ.FT.
O Z O I understand my plans shell be,used as public records.
6 SIGNS ELECTRICAL 2 nse)l'rofeseianan //O
�CLice
C6 hat I am BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
3 w vUF I hereby a Sa shut I am exempt
usin Prom the Conwnmo License law for the
IDlich re,ch.. erm,n]WLS,Business end Prof-anmvh,moAny air yor.micuty TEMP.METER OR IDLE(NST.
,4; which which reyuircsupermit.mres theutlec imProve,h permiitt or repair anyawnerc
Wok prior to issuance,vlsn.quire-Oe applicant forsuch permit.UcamignaJ statement POWER DEVICES
ty
woo Tm that he is ncing w pursue..the provisions Of she Ce Business
License Law(Chapter
a eLL 9(comhe is exempt t eeirom an the Division 3oFlhc Business tion.Anyvi la Code) SWIMMING POOL ELECTRIC VALUATION
or that 7031.5 by therefrom and the Permfonheat the
emantto civil
of
F Section T03LS by ve hmy undred
dollars(S permit subjecushe applicant t0ecivil permlty of OUTLI?TS-SWITCHES-FIXTURES
ad tml,mowban rofhe Jmddollarmyemp.
yC_ m n❑ I,esownernfNe prnpeny,ormycmplayttswiN wegeses Neirsolecompemnion, NEW RESIDENTIAL P.LECTR _gQ.ET. STORIES TYPO CONSTRUCTION
y3— will do the work,and she structure is not intended Or Offered for sale(Sec.]044,Business
mJ Professions Code:The Contractor's License Law does not apply to a owner of
property who builds or improves thereon,and who does such work hims1forthrough his OCC GROUP RES.UNITES
own employees,provided thatench improvementsme not intendeduroffered formle.If, 1
however,thabuildingce improvement is sold within one year.fecropletiin,theowner- TOTAL: /
builder will have the burden of proving that70 he did not build or improve for purpose of p
w1eJ. QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ Las the project
property4,Business
and Professions
with de-) hecontractors to
constma the prnjen(Sec.]DW,Business open Professions Code:)The ContrantO/s '
Licenu law doesnut apply toanawnerofpropeny whobuildsaimprovestherron,end PGRMI'I'ISSUANCR '
who contracts for such pmjects with acontmmor s)licensed pursuant tote Contractor's
I.icense Law. ALTER.DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE SANITARY Y N
Owner Date RECEIPTM
• covets DRAINS-FLOOR,BOOK ARFA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Ih'(2mopfLm thmlhuarave mi0cateof conscntrooftSeeureor Lab C.)whiof RECF.IPTp
Wmketx'COmpmsation Irtsuran¢or u ttnifi W c FIXTURES-PER l'RAP
Opy thereopSttJSW.Iab CJ which PARK FFP YN
all employee's under this permit GAS-F.A.SYSTEM-I INCA OUTLETS RECEIPTp
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4EA) PLANCHECK FEE
❑ Certified copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE.
COMPENSATION INSURANCE
('Phis section need not be completed Hine wrinit is Income hundred dollars(SIW) SEWER-SANITARY-STORM EA.200 P. ENERGY FEE
or IessJ
I certify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
Compensation Laws of Califamia. Date WATER SYSTEMITREATING Dal- Receipt If
0 Z Applicant
Z 0 NOTICE TO APPLICANT:IL aRr making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB, SQ.ET. TOTAL:
�+ Ln become subject to the Worker's Compensation provisions Of the labor Cale,you must _
C� 7 focthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE oI/a6
0. Q CONS9'RUCTION LENDING AGENCY SEISMIC FEE O/ ,C^'n
1 hereby affirm that Nen,is a construction lending agency fes the performance of
U O the work for which this permit is issued(Sce.3097,Civ.C.) TOTAL: Rey ELECTRIC PEE , 792 O
Lender's Name /
C) U lenPLUMBING FEC
lenders Address QTY. MECHANICAL PERMIT FEE 79. OS�
U I rectify Phut 1 have read this application and state that the above information is
cMECHANICAL FEE 17491. B
r 6w. mrcct. mu.
lagrtt.comply with all city erb etyordinancesandtamelewartlmingto A PERMIT ISSUANCE
V) building construction,and hereby authorize representatives ofthis city to enter upon the
U Z Wrove-mcntimwd property for inspection purposes. ALTER OR ADDTO MECH. CONSTRUCTIONTAX 6
(We)agree to save,indemnify antl kap harmless the City of Cupertino against Q
Iiabilites,judgntems.costs and expenses whichmuy in my wayaccrecamins[said City ATR HANDLING UNIT(TO 10,000 CFM( a/♦
inconser, of the gmntin fth permit.
/// 50-1&
0j J AIR HANDLING UNIT(OVER 10,"CFM)
Si�Tare of Applicant/Contract 2 Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO I0(),(M10 BT U) Date Receipt#
Will the applicant or future building Occupant store or handle ha eadous material HEATING UNIT(OVER I W,(KKI BTU) TOTAL:
as defined by the Cupernme Municipal Code,Chapter 9.12,and the Heahh and Safety
Cade,Section 25532(¢)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID) SO oZ.
ISSUANCE DATE
Will Ne vpplicanmrfmurebuildingoecupantumequipntemordeviuswhichemit BOILER-COMP(3HP OR IW,tMM)BTU) ppyy
. hazardous air contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0M1 BTU) 0 V
District!
❑Yes 11 No NEW RESIDENTIAL MECH. SQ.FT. AFAR 29
1 have mad zaN
the hauus materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that /s/'y
ifthe buildingdoescurrentlyncurrentlym
currently have atent,that it ismy responsibility.notify Ne to (J
occupant OI the requirements which must In met prior to issuance of a Certificate of
Occupancy.
Owner or atnhonzed agent Data TOTAL: L O ISSUED BY:
OFFICE—