27116APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OFCUPERTINO HURANINU - KLEU ''RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDEN'FIFICA'I ION
PERMIT NO.
27116
BUILDING ADDRFSS:
SANITARY NO.
APPLICATION SUBMITTAL DATE.
1) 9/ o WI I)OwJeff OJk wski LOTH
Q-6 — /
OWNERS NAME:: PHONE:
CUM 'N CTO�fS NAME: / a LIC NO:
BIC
❑
CONTROLN
� ARCIII'T[ 7 ENG[ :ER: LIC NO:
ADDRESS: a ��
CONTACT PHONE:
QTY. ELECTRIC PERMIT PEE
BUILDING PEI PLUM INFO
SLUG IiLCCI' PLUMB MECN
❑ ❑ ❑
— 610
-To e-5467-63
PERMIT ISSUANCE
LICENSED CONTRACTORS DECLARATION
1 hereby affirm Net I an licensed under provisionsofChapter9(commencingwith
Section 70(10) of Division 3 of the Business and Professions Code, and my license is in
full farce and effect. g�
License class C —; !O Lia. p
Data Conwcmr
APPLIANCES -RPSIDP.NTIAL
PANELS
UP TO
JOB DESCRIPTION
JAS" • k Ct A S ' I ll't rOAL
201 - 1000 AMPS
ARCHITECTS DF.CII. ATI
1 undersumd my plans shall he used as put m records.
OVER IOOOAMPS
SQ.fT. .00H AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licenu l Pmfcssional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm that I am exempt from the Contrucm's License Law for the
TEMP. METER OR POLE INST.
following moserm(Section 7031,5, Business and Professions Code: Any city or county
which requires a permit to construct, altar, improve, demolish, or repair any structure
Prior its its issaence, alstmmquires the applicant for such Permit o file asigned statement
POWER DEVICES
that he is license pursue..m the provisions of the Contra mir's License Law (Chapter
9(commercing with Section 7000) of Division 3 of0e Business and Professions Cee)
SWIMMING POOL ELECTRIC
VALUATION
or Nat he is exempt therefrom and the basis for alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicantto a civil poultry of
OUTLGI'S-SWITCH[S -FIXTURES
nm more than five hundred dollms($5WL
CII,esmwmero(Neproperty,rnmycmPloyecswiN wag[sus th[irsolecampensatimn,
NEW RESIDENTIAL ELIiCTR _SQ.IT.
STORITYPE
ON'TRUCDON
will do the work.and the structure is not intended oroffere forsale(Sec. 7044. Business
and professions Cade: The Contractor's License Law does not apply m an owner of
propertywhobuildsorlmprovosthemon,and whodoessuch work himselforderoughhis
own employees, convicted that such improvements arc itn
not endked or offered forma. If,
OCC. ROUP
RES. UNITS
TOTAL:
hrtweve, the building or improvement is sold within One yearofoomplmns., theowner-
builder. will have the burden of proving that he did not build or improve fm purpose of
QTY. PLUMBING PERMIT FEE
le.).
❑ I, irsowner mfthc crop[ny,emexclusivelyconwaing with littrtsedwnwctnmm
F.00DZONE
A
conswct the project (Sec. 7044,wn oBusiness and Professions Cade:) The Contractor's
License Law does not apply tom who buildsor improveathereon,and
PERMIT ISSUANCE
who contracts frrsuch projects with a cmttracmr(0 licensed pursuantothe Conmictufs
License Law.
ALTER (PA)
FEES
ARY
❑ 1 am exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
Out :1' E /V I
SITARY N
)k ILE ECI,IPTis
Owner Data
DRAINS -Fl.00R,ROOF, AREA,COND.
WORKMAN COMPENSATION DECLARATION
CI TOOL TAX
❑ I hereby affrmthat l have arciificate ofemocid toulf-insure,oraceAficareof
Workers' Compensation Imutance or ecmifiewpY thereof (Sa.38p1, Lnb CJ which
.CF.IITp
FIXTURES - PER TRAP
PARK FEE
a a 11 employee's undenhis commit
Iblicya b' s
CAS-EA.SVSTEM-1 INC.40UTLEfS ��
1: :IPfN
BUILDING IhNWISION FEIS
Company CLI !Y'
GAS- EA. SYSTEM OVER 4(EA)
PIANCHI3C '
❑ Ceniped copy is hereby famished.
Certified copy is filed with the city inspection division.
GREASE/INDUSTRL WAS TE INTERCEPTOR
GRADING FEE
C17RI'INCAI'E OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
SOILS ILE
GREASBTRAP
SEWER - SANITARY - STORM I'A. 200FT.
KNERGY FEE
('mir union at not hecomp[cted ifthe permit is forma, hundred dollars (SIM)
ism.)
WATER IIEA'fER W/VFNT/ELECIR
I certify that in the performance ofma work for which this Permit is issued, I shut[
not employ any person in any manner so as to become subject to the Workers'
Compensationlawsof CLlifomia. Dam
Applicant
WATER SYSTEM/IRPATINO
PAID
Dam Receipts
NOTICETO APPLICANT: If, eo, making this Cettificteof Exemption, youshmuld
became subject to the Worker's Compensation provisions of the Labor Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisions or this Permit shall he deemed revoke.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them iso construction lending agency home performance of
ELECTRIC FEE
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Name
Lenders Address
QTY, MECIIANICALPERMIT FEE
PLUMBING FEF.
1 certify that 1 have read this application und smte that the above information is
correct, lagrtemcomplywithnllcityundcountyordi ... cos und state laws achuing to
PERMIT ISSUANCE
MECHANICAL FEE
building convection, and hereby aultorize repres¢na Lives colds city menter upon the
also c -mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupertino against
l inbilities,judgmems, costs and expenses which yin any way accrue against said City
in consequence of 1M1e granting of Ni iia t pb/LA
AIR I IANDLING UNIT (TO 10,00) CFM)
AIR HANDLING UNIT (OVER Il" CFM7
marc Applicant/Commute, Dee
EXHAUST HOOD(W/DUC)
PAID
HEATING UNIT (TO 100,ODO BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt a
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
I[RATING UNIT(OVER 100,0(0 BTU)
TOT
Code, Section 25532(2)'1
❑ Yes ❑ No
VEITHLATION FAN (SINGLE RFSID)
BOILER- COMP QHP OR I W." BTU)
ISSUANCE DATE
_
Will thea licumor future buitdin ocev
pp g pantuuequipmenmrdevicn which emit
Wous air contaminants m defined by the Bay Area AG Quality Management
Cami
lcl'!
BOILER - COMP(OVER 100,000 BTU)
Ct
❑ Yes ❑ No
-6
('
1994
NEW RESIDENAL. MEC11.
TI SQ. FT.
1 have rtad the hard
zamm materials requirements under Chapter 6.95 of the
Cir r L/f
California Health & Safety Code, Sections 25505, 25533 and 25534, l undentand that
if the building does not
asthe that itis myresponsibility tenotify flue
V dr
mCarmody ts whave
occupant of In, requirements which must he and prior m issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or authmicim ¢gem Dam
TOTAL:
OFFICE