27973 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
INE
Y OF CUPERTINO It IL PERMITNO.
LTI LDINODIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27973
BUILDING PROJECT IDENTIFICATION
Imo/ NOADDRF,SS: �j) SANI'TARYNO. APPLICATION SUBMITTAL DATE
2. 4 / UNIT# IAT#
RSNAMB: PHONE: ONTUkC0 S NAMB: LIC NO:
VT G Q ,}e� pp)) NIC CONTROL#
RCIII'IBCT TN G w�Y^ LIC NO: AD/O TIO a /X iT 14 V/•
CONTACT: 11 PHONE: 'tzuq� tl y BUILDING PERMIT INFO
V3� a�,fXd„FELECI7UC PERMIT FEE
BO 1 H O1AVA �LQG ELECT PLUMB MECH
PERMIT -�I-�IIj, � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTIONizwz, Ihereby affirm that l am licensed under provisions ofCTapher 9(commencing with
V100 Section 7000)of Division 3offle Business and Professions Code,and my license is in PANELS
5dtall force and effect.
ss. Lt..Class Lic.It UP T0200 AMPS L
Fn=y Dom Comractor 201-1000 AMPS
.nZ ARCHITINS DECLARATION OVER IBM AMPS SQ.FT.FLOOR AREA $6Q.Ff.
y I undersand my plana shall be used as public recomx.
y(r SIGNS ELECTRICAL
qa' Licensed Professional
g� that
Ian DUH.DEnDECLARATION SPECIAL CIRCUIT/MISC.
KOEU Ihereby uffitm thm 1 am exempt form the Conuumis License law for the
W 3 0 y following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
F3 which requires a permit to ci n menet,slot,improve,demolish.w repair any etrvcmre
N� feriortn In issuance,also requires the applicant frrsuch lanolin,file a signed statement POWER DEVICES
p0 that he is licensed pursuant to Ne provisions of the Contmcuors License Low(Chapter
o.aoFo 9(commenciagwiNSeedon 70M)of DNisicn3ofthe Businessaml Professions Code) SWIMMING POOL ELECTRIC VALUATION
WM,, in that he is exempt domin m and the basis for the alleged exemption.Any violation of
kZ6 Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of OUTLETS-SWITCHES-FIXTURES
not more than five hundred dollars($500).C NEW RESIDENTIAL F.LECIR E .FT.p ❑ 1,avownerafthcpropeny,armyemployeeawiNweges astheirsolecompcmenaa, Q STORIES TYPECONSTRUCIIDN
a3o0 willdo the work,mod the aucmre is notlmended oroffered for sale(See.7044.Bmiaess
end Professions Code:The Contractor's License Law does not apply to an owner of
property who buildsuriaraoves thercon,ond wh,does suchworkhimulforthrough his OCC.GROUP RES.UNITS
own employees,p angor improvement thensuch improvementsare not intended oroffered for o e. r.
however.Neavete lanrviissoldhe withinoneilderi prove ognbeose,if TOTAL:
builder will have the burden of proving Ihns he did mol build or improve for puryau of
sale.).
0 Los owner ofthe prole y ycontractingwi QTY: '. _ PLUMBING'PERMI'f FEEFLOOD ZONE APN
construct the project(Sae.o1 o Business and Professions Code)The Conuac end M
License Lawdasnoupply man ownernfpropertywhobuilJxorimprovcsthertan,end PERMIT ISSUANCE
whocamen forsuch projecta with aconu¢mr(s)licensed pursaanuothe ConvectIIId
ors ALTER-DRAINA,VT-WATER FA) FEESUMMARY
License Law.
m
®1 an exempt under Sec. .B @ P C for this reason BACK FLOW PROTE (DEVICE OUTS ID: au
11, SANITARY Y N
Ownc Dam RECEIPT'#
$ WORK AN COMPENSATION FECLARATION DRAINS-FLOOR.ROO .AREA,COND. CHOOI.TA% Y N
❑ I hereby affirm that l have a cenificao of comm to self-insure,w a certificate of FIXTURES-PER TRAP RECEIPT'#
Workers'Compensation lasurancom a certified copy therem(Sec.380.Lab CJ which 1 P RK FEE Y N
covare all empp��pp pd this pe O GAS-EA.SYSTEM-1 INC. OUTLET'S IUiCF.IPI'#
Psmeyp Y10�//AO D�ys"I✓Ptr—,i q- � BUILDING DIVI ON ES
Cnmpany�aT'#�as^—�4 N"s'a GAS-EA.SYSTEM-OVER (EA) P HECKFEE
❑ Cenifedcopyisherehyfumished. R;wisiV 46%
❑ CenifiedeWy is filed with the city inspection division. GREASPANDUSTRLWAS INTERCEPTOR GRAD GHE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS
COMPENSATION INSURANCE
(This section tad not be completed if the permit isfwonehundrM dollars(SIM) FEWER-SANITARY-STOR EA.200FT. ENERGY AVE
or less.)
I certify that in the performance of the work for which this Permit is issued,l shall WATER HEATER W/VENT/E CTR
not employ any parson is any maser so as m became subject to Ne Worke.' PAID
Compensation Lawsof California. Dme WATER SYSTEMITREATTNG Da Reccipt#
O Z Applicant
O NOTICE TO APPLICANT:If,after making this Contra..of Eumption, mit should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
Fres becomesubjeaa Ne Worker's Compensation provisions of the Labor Code,you must BIRDI E �"
> "With comply with such provisions or this permit shall 4 darned revoked.
4k1 Q -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affren that there is o construction lending agency for the performance of
zTOTAL: ELECTRIC FEF,
U O the work for which nh�'sBerenin is iss`i(Sec.309],Civ.CJ
I2. Leader's Name�_]L� - - ,
C) Lender's Address QTY:r"" ' MECHANICAL PERMIT FEE PLUMBING FEE
Uj 1 certify Nat T have read this application and sou that the above information is - MECHANICAL FIX
csarsoct lagramcomply with Vl tiny erns caunry wdinences end sate laws relating to PERMIT ISSUANCE
ybuidingeonstructi,n,and hereby authmire representsdvesofffin city no ems upon the CONSTRUCTION TAX
L) z aMwc-mentioned praperty for inspection purposes. ALTE-RORADDTOMF.CH.
(We)agree to save,indemnify and kap hvmless the City of Cupertino against
Habilitiesjudgmems,costs and expenses which my in my way accrue against said City AIR HANDLING UNIT(TO 10,"CFM)
in equen f the¢¢¢rrraaannnring,Tibia pe
i cons �J��(��/��/ AIR HANDLING UNIT(OVER IO,(IOO CPM)
Si,m6nLn,mff ApplicanVCo.mwmr Dow EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE, HEATING UNIT(TO IM.Off) Data Receipt
Will the applicant or from,building occupant store or handle haeardom material HEATING UNIT(OVER 100,1100 BTU) TOT
u defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
Cade,Section 2Yes
VENTILATION FAN(SINGLE RPSID) r
BOILER-COME(311P OR IW,WB BTIE ISPAN L�QTE
Will the opplicamorfuturebuiliing occupennuu oquipmentordeviceswhich emit d/ A v
hsaardpus air conaminanls as definN by the Boy Area Air Quality Management BOILER-GOMP(OVER Ifp,W(i BTI)
Disuict1 �I
❑Yee P-11'.' NEW RESIDENTIAL MECII. SQ.Ff. MPR 241995
1 have read the hazardous maorials requirements under Chapter 6.95 of rhe
California Health&Safety Code,Sections 25505,25533 and 25534. 1undersand that C��Y U (cul!
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requi emus hich sn be met prior m tseuance of a Ce 'ficateof
Occupancy.
Covourconufficarri'lirtsal Dud TOTAL: ISSUED BY:
OFFICE