27277APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO:DING-FUR77Frtl.^
APPLICATION/PERMIT PLUMBING - MECHANICAL7277
BUILDING DIVISION BALDING PROJECT II ifirl IFICATION
PERMIT NO.
BUILDINGADDRES4: /I' /(�1'
V will s� / UNIT# LOT
SANITARY NO.
APPLICATION SUBMITTAL DATE
' ����
OWNI3 'NA I?: PHONE:
CO TR8C1'O'SNAME: LICN
N/C
3 ❑
C(INTROLN
i fQ r r
�/��0 M 4,So Iv
ARCIII' E UENGINEER: LIC NO:
ADDRESS:
5 89 N C -C 6Ck..,p r San .$ti (',� 9 s'/
e1OnNNTAACr: PHONIriB[IILDING
r r, y �(� I' i e ��'l�eY ���1 •1 1 I d`�
QTY ELECTRIC PERMIT FEE
PERMIT INFO
_
BL ELECT PLUMB MECH
PERMIT ISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hcrchy affiant that 1 am licensed under provlslonsid Chapter9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DLSCR
PANELS
Hp Tp 200 AMPS
Section 7")of Division 3 of the Business and Professions Code, and my license is in
full rumored affect.yy S`.
.ice Cl LIC.X d7}'WNJr'{
Dae Contractor
201 - I" AMPS
ARCIII"I'ECTS DECLARATION
1 understand my plans shall be used ns public mcmds.
SQ. FT. FLOOR AREA
S/SQ. FT.
OVER 1000 AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCOTDMISC.
I hereby or.... that 1 am exempt from the ContraGods License Law for the
TEMP. MBIER OR POLE INST.
following reason. (Section 7031.5, Businessand Professions Code: Any city orementy
which rtquires o permit to comuua, alter, improve. demolish, in repair my structure
prima. as issuance, also requires the applicant for such permit to fileesignedsduchans
POWER DEVICES
that he is licensed punumt to the provisions of the Contractor's License Law (CTapher
9(commmeing with Section 7") of Division or the Business and Professions Code)
or that he is exempt themfnrinl the basis for bandaged exemption. An,Aidiionof
Section 7031.5bymyapplicantfar a permit subject. the applicanuo a civil penalty of
nre
t mothan five hundred collars ($500).
❑ 1,asownerofthepropeny,ormyemployeeswithwagesastheirsolecompensm
SWIMMING POOL ELECTRIC
� VALU/,TION
Baa G
-
OUTLETSSWITCFIFS - FIXTURES
.
NEW RESIDENTIAL ELECR 5FT.ion. Q
STORIES
TYPECONSTR LHON
will clothe work, and the structure is not intendecororratd for sale(Set 7044. Business
and Profea)Inns Code: The Cmucie n 6 Limens, Law does not apply in art awaer of
pmpertywhobuildsorimproveathemOn, and had. such wart himulforthroughhis
ownemployees,pmvidedthatsuchimpmvemenuummitenaedorofferedfmsole. If.
OCC. GROUP
RFS. UNITS
TOTAL:
however, the building or improvement is sold within one-year ofcompleaon, the owner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBINO PERMIT FEE
sale.).
❑ 1, usowncruf@e pmpeny,mmxdusivelyamhaaing with liumdconwmonto
FLOODZONH
APN
contact the project (Sec. 7064, Business and Professions Code:) The Contractor's
License Lawdoes not applym an ownerofpmperry whobuildsorimprovesthercnn,and
PERMIT ISSUANCE
who contracts frosuch projects with a cmhractods) licensee pursuant tothe Comemon'e
License [.a..
ALTER - DRAIN &VEN'L'-WAPER O?A)
TLe
ISUMMARY
❑ 1 am exempt under Sec. , B & P C for this rcsson
BACK FLOW PROTECT. DEVICE
SID • '
SANITARY Y N
RECEIPTN
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND. -
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Iherchy affirm thntlhaveucenificeto of comemmself-insure, oraanilicem of
Worken'Compcnsaion lnsunnm or eceni0ed copy therwf(Sec.3B00,lab CJ whichARKI
RECEIPTp
FIXTURES - PER TRAP
Y N
vaIcan ellemploya's under Nis pe t _
�ail'T �w a�
RECEIPOp
GAS-EA.SYSTEM-I INC.40 LETS '
BUILDING DIVISION FEES
Company Si m
Contra,
GAS - EA. SYSTEM -OVER 4(CA
LANCIIECK FEE
y❑ 4enified copy is hereby
GRFASFJINDUSTRI. WASTE •RC[PTOR CUMGRADING
FEE
tficanhe
with
CcdifiW copy is filed with the cityimpation division.
city
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
OILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA 200FT. 4
F.RGY FEE '
(This section need not becumplmed ifthe permit is for one hundred dollars rU00)
or leu.)
WATER HEATER W/VENT/ELE
I certify thin in the performance of the work for which this permit is issued, I shall
not employ any person in my roamer so u to become subject to the Workers'
P ID
Compemationlawsof California. Date
WATER SYSTEMITREATING
Data Receipt
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. FT
IAL:
become subject to the Wo lde's Compensation provisions of the Labor Code, you must
foMwith comply withsuch provisions or this permit shell be domed revoked.
BUI DING FEE
SEISMIC FEE ISO
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat Nem is issuedU xco3 lending agency for Ne perfonswrce of
the work for which this pcnrdt is issued (See. 3097. Civ. CJ
TOTAL:
ELECTRIC FEE
Lender's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I codify Nat I have read this application and state that the above information is
correct, lagrcemcomply with ell city and wumy oNinmces end stem laws mlelingm
PERMIT ISSUANCE
MECHANICAL FEF.
building cmtetnction, and hereby authorise rryrcuntatives of this city to enter upon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) done to save, indemnify an keep harmless the City of Cupertino against
liabilitiesJudgments, ansa exol'penseawhlchmayinmyway accrue against said City
AIR HANDLING UNI'1•('1'O 10,0011 CFM)
in cnnaeyucnc of the ng this permit,
/ :5--1
7
iign
AIR AIR HANDLING UNIT (OVER 10,001) CFM)
f pplicnndComructor Date
EXHAUSTHOOD(W/DUCf)
PAID
HEATING UNIT (TO 100,001) BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Rcaipt#
Will the applicant or future building occupant store or hostile ha eadous material
ie defined by the Cupmino Municipal Cade, Chapter 9. 12. and the Health and Safety
HEATING UNIT (OVER IM.000 BTU)
Cale, Section 25532001
CI yes ❑ No
VENTILATION FAN (SINGLE RESID)
//��
Y
Will theapplicdmarfummbuildingmcupam uuequipmca or deviaswhichcmit
AI� IS QE DATE
'v V
BOILER- COMP(3HPOR 100.000BTU)
BOILER -COMP (OVER 100,000 BTU)imne
naoaN1m air contaminants as defined by the Bay Arta Air Quality Menagaunt
f/�
13 yes E) No
(,/�, 49*
NEW RHSIDHNTIAL MECII. SQ. FT.
1 have rand the hazardous materials "tulecmente under Chapter 6.95 of the
California
Califmmia Heahh & Safety Code, Sections 25505, 25533 and 25534. 1 understand Nat
if the building does not currently have a tenant, that it is my re,ahmemility to notify the
V -
,I
ha
occepmd of the rc u' which m et prior to issuance of a Cad cuI of
<upmcy.
ISSUED BY:
wnerar oriesd agent D
TOTAL:
OFFICE