27185 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,USE BALL POINT PEN ONLY
CITY OF CUPERTINO m1111=IrEL.. PERM]I NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING.PROJP61IDENTIFICATION 27185
MILD/INGG ADDRESS: R
pRESSL �O SANITARY NO. A 'LICAIA I
ON SUBMIT)At.DT
Deoep rarH,, ze UNIT LOT is �e' let1
OW 'NAME: PHONE: C TRACTOR'S NAME: LICNO;
WC CONTROLN
. tidfV i9A2GiEnf 252-r"G cw.l�r�
�.•ARCfI1TECT/F14GINEER: LIC NO: )DRESS: ❑
.Gal
CDNI'ACy' PHONE 4157
g��7 QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
PERMIT ISSUANCE L ELECT PLUMB MECH
M R
LICENSED CONI DECLARATIONTtl 11 El 0
APPLIANCES-RESIDENTIAL W )OB DESCRIPTION
WOO I hereby 0M)of rin Division
]am lira, od Busma er s=it it fifes of'Cions apner Code,and my license
with
WOO Seaion]IIoO)of Divis on3of the Business and Professions Cade,and my liame is in PANELS /N , /ate
U full force and effect. t UP T0200 AMPS Fµ� w
FZ W License Class Lia.N
i,<- Date Comncmr 201-1000 AMPS
/�Nz ARCHITECTS DECLARATION OVER IOIX)AMPS SQ.ET.FLOOR AR EA WSQ,FT.
OZ—D Iu_RnwnA my Pon
shall be used sapublicamimb.
SIGNS ELECTRICAL
6y E,,j Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUD/MISC.
XOyF 1 hereby uffmt that 1 am exempt firm the ContractorN
's License Law for e
W3Wm followingieemn.(Section 7031.5.Business and Rofessions Code:Any city orcounty TEMP.METER OR POLE INST.
F'
1110I wIbich re,m,a perma n.construct,alter,improve,demolish,se ieWir any structure
wik:tvor
� Phil,,.its issuance also requiresthe upplic.m fofxuch rnit to ft lea signed ataten POWER DEVICES
that he is licensed pursuant o the provisions of the Contractors License Law(Chapter
u. c'
(commencing with Section 70M)of Division 3 ofthe Busi nese and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
w^y or that he is exempt themfrom and the for the alleged exemption.Any violation of
~-Q Secmo 71)3 LS M1y any upplicam GnuPermit suhjens the applicannu ucivil penahy of OUTLETS-SWITCHES-FIXTURES
Glp reChad five hundred dollars($500). NF.W RESIDENTIAL ELECfR _SG�IxII
WFC 1.as nwner niche property,or my employees with wages as their aide compensation, STORIES TYPE CONSTRUCTION
e'3 will -work.and the structure is not intended moffered forsde Ses.7044,Business
and Professions Code:The Contractors License Law does not apply m an owner of
pmpenywhobudds orimpmves thermo,and whodoessuch work himsclforthmugh his
cmpinyccn.providcd that such impmvancntxum notimcndedoraffared formle.if, I OCC.GROUP RIS.UNITS
however,the building or improvement is sold within oneyear of compleion,theowner
-
builderwillhavetheburdcaof that he did not build m ire for TOIAI"
proving prove purpose of
u]c).
❑ 1,as owncrof the property,wn exclusively contracting withliccnsedcdnuadonw QTY. PLUMBING PERMIT FEE OOD LONE pPN
construct the project(Sec.7044,Business and Rofessions Cale:)The Cnntrador's
LicenseLaw dovrnm apply loan ownerofproperty whobulldsor improves theron.and PERMIT ISSUANCE
whence L.contracts projects with acono-.mo��7licensed PumaummAte Contractor ALTER FA _ FEE SUMMARY
License Law. ( )
❑nl am exempt unAer Sec ,B&P C for this rewon OUTSIDE FEES
HACK Flow PROTECT.DEVICE SA 1P lY Y N
Owner Uate DRAINS-FLOORROOPAREAGOND. RECEIPT0
. , ,
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IhemM1y affirm Nmlh�ve nemifeutc nfenreenl In self inmrt,orneerlifcute of RECEIPPN
FIXTURES PER TRAP
Workers' dxu
Compenaation lranor
tt acenifiedcopY thereof(Ss.3g00,labCJ which PARK PIiG YN
rovers all employee's under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPTN
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYST iM-OVE114 EA) PLANCHECK FEE
❑ Cmired copy is hereby mmiahw.
❑ CcnilieJ copy is fled with Ne city inapeaion tlivision. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GkEASETRAP SOILS FEE
COMPENSATION INSURANCE
This section need not be completed i(the Permit is for one hundreddollas(SIM) SEWER-SANITARY-STORM EA.2MFE. ENERGY FEF,
or less.)
I eenify that in the perfommnce of the work for which this permit is iuved.I Nall WATER HEALER W/VFM/ELECTR
not employ any Icmon in any m as m become subject te the Worker, PAID
CnmporNsonlawsof Celifomia. Date so WATER SYSTEM/TR L- TING Date Receipt N
Q z Applicant
z O NOTICE TO APPLICANT:If after making this Certificate of Exemption,you should NEW RESIDENTIAL ELME. SQ.FT. 'TOTAL:
F" ` become mhjeauphe Worker's Cora,mi ion provisions ofthe Luba Code,you somal
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE 01
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
U O the work for wh6 h this permit is issued(Sm.3097,Civ.C.) TOTAL: aECTR IC I'EE
Leaders Name AddPLUMBING PEE,
p F- Lenders ress QTY. MECHANICAL PERMIT FEE
U I cents,thus 1 have mad this application and state,hat the above information is MECHANICAL FEIi
>. LEA rotten.Iagrm mcomply with all city send county ordinanccx and sate Iowa mlatingm PERMIT ISSUANCE
building e.niamehoo,and hembyuuthorim represcnativoo(this city te enter upon the CONSTRUCI'IONTAX
U above-mentioned prpeny for im"lion purposes. ALTER OR ADD TO MECIL
WO ugme m save,indemnify and kap harmless the City of Cupertino agalms
liabilities,judgments,cons and expemes which may in any way accrucagainxsxuid City AIR HANDLING UNI'f(TO 10.00)CFM)
cdnscquc the .mtingoflhis Pe
AIR HANDLING LIST'(OVER IU.WU CFM)
arum of Applicant/Cnmrvmr Dale EKIIAUSTHOOD(W/DUCT) PAID
IIALARDOIISMA'TF,RIAISDISCI.OSURB HEATINGUND('1'OIW.Uq)BTU) Date Receipt#
Will the applicant or future building necepant more or handle harndme,matin.]
as defined by the Cupenimo Municipal Code,Chapter 9.12,and the Health and Sales, HEATING UNIT(OVER hs),000 BTU) TOTAL.:
Code,Smi El Yea ❑ No 253J2(a)?
❑ VENTILATION VAN(SINGLE RISID)
Will thea llumtorfutum buddin BOILER-CO ME Ld W OR IM,0W BTU)
ISSUANCE DATE
PP 8cecupuct umeyuipmemordcvias whichcmit
heav1 he'...air conmminram m dan
defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100."BTU)
e
ID Yes ❑No NEW RESIDENTIAL MECH. Q..FT.
49 _
1 have read the feamdoux mctionss 5505.25533 under Chapter 6.95 of the
CelifomiaHdth&S.fcur Cale,ave Sections and 23534. Thyrotancersould
roof that
occupaifthe ofbuilding daequir menta]ly which must
he met o is my mporsuancxibf a Ce micat the (ti� 9199'
¢cup;tm of the myuircn¢nu which muss be ten prior so issuance of a Certificate of OCTV I
Oecammry.
L!EY V
Owner or authnriecd.gem Date TOTAL: ISSUED BY:r L
OFFICE