27967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ItUtIMINOrel.I!MI PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROD j,JADXNFIFICATION 27967
BUILDING AUURI3SS: 1 SANITARY NO. APPLICATION StIBlvirriAI.DA3'E
.UNIT a LOT g
ctW iR' AMI? PI E: C RACI'OR'SNAME: LICN : iii•
R11N/C CONT OLa
ACHITEM/ENGINL'ER: LIC NO: 7d:` �� ❑
CONTACT: PHONE: J1/�1AJ BUILDING PERMIT INFO
QTY. y ELECTRIC PERMIT FEF.
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I� 11 E3
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTW, 1� TOB DESCRIPTION
❑❑❑❑yw 0Z Thereby affirm that Into licensed underprovisionsmChapter9(commencing with
�00 full forcemdefecivision3ofthe Business and Professions Code,and my licemeis in PANELS -
Z, full force and effect.
License Class Lica IIP T0200AMP5 3 icy
vt?y Dae Conwaor 201.1000AMPS
ZOo,z ARCHITECT'S DECLARATION OVER I00p AMPS SQ.IT.FLOG AREA S/,Q.FT.
07. qqq 1 understand my plans boll be used as public record.. _
r4SIGNS ELECTRICAL
a Licensed Prol'esslonxl
C�
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaF I hereby affmr, that 1 am exempt from the Contractors License Taw for the
30Oy following rtamn.(Section7031.5,Business and Professions Code:Any city m county TEMP.METER OR POLE MST.
which mquirn op:mrit no construct,.Iter,improve.demolish,or repair any amrcore
priormits issuance,also requires the applicant for such permit m file a signed statement POWER DEVICES
pursuant C<0 that he is licensed to the proviso of the Contractor's License Law(Chapter
Y. 9(coSWIMMING POOL ELECTRIC
VALUATION
Py mthatheisexemptTherefromand the basis for the alleged exemption,Any violation of OUTLETS-SWITCHES-FIXTURES 0c)
7= act Section
iv any hundred
olars H5 mit subjects the npplicmttoecivil Penalty af
WrZ nm mare NanrofhcM Ay, m(SSm). NEWRFSIDENTIALELECR S FT.
m ❑ othe wnero0d thesony,m,a.,onoyeeswiNwagnesthei(See compenmtlen, Q' STORIES TYPF.CONSTRUCTION
will do the work,end the he Con ectol'sLice se awdoes not apply
0an Business
and Profwh ons Cede:The C.mruemr's tad whe Lew does not apply if an owner of
proown enywyees,ldsorimprovcschcraa,nndwbodmess.ch work tendedioffenr Nmnghhls OCC.GROUP RES.UNITS
n employees,providedNa suchent is sold within
earoedmpletiod Parole.If,
hiller ,will
eavete burden
that a di inoneyem orcomrial,for
purpose f TOTAL:
builder will have the buNrn.(proving Nm he did not build or improve far purpose of
ole.).
❑ I,as ownernflbepropeny,emexclusivelycantmaing wiN licrnsW nmvecmnto QTY' PLUMBING PERMIT FF.F? -----Tl ODD ZONE APN
construct the project(Sec.7014,Business and Profcssimm Code)The Cnmrotor's PERMIT ISSUANCE
Licence Lawdnes not.pplYno mnwnenefpropeny whnhuilJsmrimprova thereon,and
whocontraca forsuch projects with acommcmr(s)licensed Pnrsuenaothe Cmmmctor'a ALTER LA FI?C•SUMMARY
License Law. ( )
❑ I am exempt under Sa. ,B A Is C for this moon BACK FLOW PROTECT.DEVICE
OUTSIDEFIES
IOwnerDate
s SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOP,AREA,GOND, RECETP17N
SCHOOLTAX Y
❑ IM1ercby nflirm Nmlh.vcuartifeme of consemmxelf-Insure,aracertifice¢of
RECEIPT.
Workers'Compensanimn Insurance ore ceni0ed wpy thereof(Sec.3glq,Leb CJ which FIXTURES-PER TRAP PARK FU13 YN
covers all employee's under this permit. GAS-EA.SYSTEM. INC.4 OUTLETS IllEIPT a
Policy a BUILDING D VISION FEES
Company
❑ Certified copy is hereby famished. GAS-EA.SYSTEM OVER 4(EA) PLANCHECK FEE
❑ CerifW copy is filed wi,h,ha city inspection division. GREASPpNDUSTRL WASTE INTERCEPTOR GRADING FEE'
4
CERTIFICATECOMPEOil NSATION
ATION INSURANCE
NFRAN WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
This-tionneW.1la,completed if Ne pcmdt is formal hundred dollars 1$100) SEWER-SANITARY-STORM EA.200 p. ENERGY FEE
or I..)
I certify that in the permarran.of he work for which Nis Permit is issued,Ishall WATER HEATER W/VEbIT/ELEC134
not employ, any person in any mannas m become subject to the Workers' PAID
Z Compensati x Calif. Um WATER SYSTEM/TRHA'TING Date Reccipta
p NOTIApplCnt
�sy NOyGCEbjeAI�IeAaT:If,Compensation
PrCcnons of th Labor iuri.yom..a, NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
D+ (n becowithcoxtm the Wariksuch Cmnp.or its Permit Aid!
Nelabmr Curti. oras[
tat^ ; forthwith comply won such provision.or this permit andl be deemed invoked. BUILDING FEE - 00
4U Q CONSTRUCTION LENDING AGENCY SEISMIC FEE `?`ro
z Iherebyuf0rm
that there i.a cnnavucti.n lending agency for the perronnnnce of TOTAL: ELECTRIC PEE
O m
the work for which this peut is issued(Sec.309],Civ.C.)
Lender's Name PLUMBING FEE
- lenders Address - QTY, MECIIANICALPERMIT FEE
0 W I ttnify that I have read this application and sate then the above information is MECHANICAL FEE
mnect.Iagonmemmplywithalleityeadecony.tell....and sate law..].It.,to PERMIT ISSUANCE
y building comRllclier,and hereby amhudae.pmsenativn ofthiscity to enter upon the CONSTRUCTION TAX
V 7 dove-memianed pmpen
y far inspection purposes. ALTER OR ADD TO MECH.
F7 (We)agora to ova,indemnify and keep harmless the City of Cupertino.,.last
Iiabilities,judgmems,costs an pens.which mayor aaga
y aacrueimts.id City AIR HANDLING UNIT(TO 10,000 CFM) AVA
me asuenoc. he, in Nis trait.
AIR HANDLING UNIT(OVER 10,0010 CFM)
Sign ture. Applmot m ser Dam EXHAUST HOOD IW/OUCT)
PAID a
HAZARDOUS MATERIALS DISCLOSURE BEAT'ING UNIT IT I00,000 BTU) l Uham\ Receipt�#
Will the applicant or future building occupant store or hzadle h.zvdous material I{EATING UNIT(OVER IOf).(g0 B'TU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.LZ and Ne Health and Safety
Code.Section
Yes El No 25912fa)?
❑ VENTILATION FAN ISINGLB RFSTDI
Will the aconcunmrftnun defined by the use Area enwuality Maragunia
BOILER-Comp QHP OR 100,000 BTU) ISSUANCE DATE
Distrdom reit e.memin;mu as defined by the Bey Area Air Quality Munag9nunl BOILER.COMP OVER IOg000 BTU) Sn� pg
District? ( P i'i
ID
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.ff.
I have mad the h.rardous maeri.ls re uiremena undo Chapter 6.95 of the APR 21 1995
Califnmi.11nitb&S.fety Code,Sectiun.25505,25533 end 25534.1 undersand Net
if the building does not currently have it tenant,that it is my responsibility to notify the
mcupam of the rcquiremnms which tram be met prior nr isxuunw of a Ccrtificme of GI IT Vf VUrCrl I INU
Occupancy.
Owner m authm[ired agent Date TOTAL:IISSUED BY: