27161 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - FRICAI- PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 27161 7 q1 6 e,
BUILDING PROJECT IDF.N'fIFICATRN G 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMTITAL DATE
W NIT# \ LOTp lO�
OWNERS NAME: ` 1 ` , ..PHONE: NTRACTO NAMG: /�� LIC NO:
Iw�V NJ V4. / F� �Y/ l N/C CONTROL.p
ARCI II I H, I iNGINEER: +�� �w LIC NO: DRESS: \Y M+�^' ❑
is
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG EL PLUM MECH
MI
PERT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL LOB DESCRIPTION
Qwz I hereby affem Cb
that l am licensed under provisionsofapter9(commencingwith
PJOO Section 7(100)of Division 3 ofthe Business and Professi.ria Cock,and my limmsm is in PANELS
Flu fall License
Cluforcomdeffect /x /1_��
F ZU,it Licence Class Lic.p IIP TO 2W AMPS `s ter-{✓1
QaDq me Contacmr 201-LBW AMPS
zOy— ARCHITECTS DECLARATION OVER 1000 AMPS SQ.IT.FLOOR AREA S/SQ.Pr.
CZ-0 I understand my plans Shan h used as public records. �O�� {}� LO�
F;�d 41 SIGNS ELECTRICAL 1LT11`�
Lqy <] LteenseA Professional
OWNER-BUILDERm the Contractor's
SPECIAL CRtCUIT/MISC.
5�544'O yE 1 hereby nffrm that 1 ER exempt from theRATA License Low for the
t+131a.m following reason(S«don 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE]NST.
1=f.S�� which rtquiresnpermit m mnstrum,.heq improve,demolish,.,aIaiu i,mn ma
E Y2 PH-'I- issuan-,-is-ayulrcathe.pplicam formch Permit mo file.signed satemet POWER DEVICES
yajG <O thin he is licensed parsuanuombe provisions ofthe Cconnawrs License Law(Cbepter SWIMMING POOL ELECTRIC
o.Is. 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) VAIAA'TION
y�y or that he is exempt herefrom and the basis for the alleged exemption Any violation of SW
OUTLETS- ITCHES-FIXTURES
z Q Section 7031.5 by any app)icam for.Ismout mbjems the appli num m a civil penaty of
not mom than rive hundred do])..($500). NEW RESIDENTIAL ELECTR S FT.
❑ 1,asuwncmOhepropeny,ormyempinyces widen wagesastharsolecompcnsadon, Q' STORIES TYPECONSTRUC iON
per, willdomhc work,and the mmcture isnat immndedoroffemdforsale(S«.7W,Buemss
it Profess ns Cade:The Contractor's License law does not apply to an owner of
propeny who buildsorimpmvesthemon,and whodoes such work himaelf.rthmughhis
ownemployeas,pmvide tlatsuchimpmvementsaanotinkndWoroffemdforsae.IL OCC.GROUP RES.UNITS
however,the buildings imiummememn is sold within ane yesrofcampledon,themener-
builder .will have the burden of in Dam he did not build or im 1
moving prove for purpose of
tee.).
❑ Lusowneraftheproperty,emexclusively contracting wish licenud contract-n mo QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
nstmct the project(Sec.7044,Business and Professions Code:)The Courommor's
License L Loc does not applytoanowner-fpropeny whobuildsor improves chimera,and PERMIT ISSUANCE
who contracts!-,such projects with a cortmetor(a licensed pursuant in the Coalrucbr's ALTER (PA)
License law. EEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C far this reason BACK FLOW PROTECT.DEVICEOUT91DIFFEEN
SANITARY Y N
Owner Dam RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
• ❑
Workers'
affirmthat
ommunc have a ma
a come dconsemmof(Sesua,orace C.)which Fl%TURES-PER TRAP RECEIPT'#
Wskers C-mpensation Imurarice ora emoted copy thereof(Sec.3gW,Lab C.)which PARK HE
covers all employee's under this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS
Policy# BUI G I SI
FEES
Company
❑ C<nifiM copy is hereby famished. GAS-EA,SYSTEM-OVER 4(EA) PLANCNECK FF
Cl Certified copy is filed with Neciry inspcmion division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEEII ll'
1 ��
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nut be completed lithe permit is forone hundred doll.(S IW) SEWER-SANITARY-STORM EA.2(mFT. ENERGY FEE
or leax.)
I certify that in the performance of Nmi
IN
e work forwhich this pert is issued,I shall WATER HEATER W/VF,NpELECOt
Ito
not employ any Person in any Header so m to become subject to the Wor[cm% PAID
Compensation Lawsaf C.lif-min, Date WATER SYSTEM/IREATING Dale «cipt#
OQ NOTICE'
TO APPLICANT:1[after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB.. SQ.FT. TAL:
V) becomesubj«uo the Wake.Compenation provisions ofth.Labor Code,you most
� forthwith comply with such provisions or this perut shall#deemed invoked. BUILDING FEE, d
ILI
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE O
1 hereby oM.Nara them is a corummim.lending agency for the perforumce of TOTAL: ELECTRIC FEE
V O the work far which this pemit is issued(Sec.3N7,Civ.C.)
U. Lender's Name PLUMBING FEE
Lenders Address QTY, MECHANICAL PERMIT FEE
U
a 1 certify that I have read this application and sate that the above information is
c.rmct.1.,tn,mc-mply wiNall city music..nryordinancaandstatelewsrehringto 1 PERMITISSUANCE MECHANICALFEE
�-t building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTIONTA% O
I,.) above-mentioned pmperty,for inspection purposes. ALTER OR ADDTO MECH.
(We).gr«m save,indemnify add keep harrkss the City of Cupertino against _e
liabilities,judgments,costs andexpenseawhich may in any way same against said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
incmoe9ue the I]!Of mhos Writ. _jq
I AIR HANDLING UNIT(OVER 10,000 CFM)
Signatureof Apahma*C-nrmenr Date EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MA :RIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER R)RW BTU) CVtTA
Code,SeeHim 25532(.)? VENTILATION FAN(SINGLE.REBID) L
❑Yea ❑No
Will the applicant orfta.building occupantay Am p Air ualityc M....inmim
BOILER-COMP(311P OR 100,0)11 RTU) ISSUANCE DATE
harard.us air comnarnin.nts is dcfinW by the Bay Arte Air Quality Mvnegement
District? BOILER-COMP(OVER 100,"BTU) A
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. It
1 have reed the hazardous mamenals requirements under Chapter 6.95 of the !s! 'gig
California 1leath&Safety Code,Sections 25505,25533 and 25534.1 understand thatmm19 Y n�
lithe building does not currently have ate �L that it is my responsibility tomaify the /- k7
cupant of the mquiremrants which must be met prior to issuance ref.Certificate of U~Q
Occupancy, /
Owner or aumh.r ad agent Date TOTAL: ISSUED RY:
OFFICE