27442 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO BUILUI ,-ME MECHANICAL PF:RMI"T NO.
APPLICATION/PERMIT PINGPROG-MPICHANIFIC
BUILDING DIVISION tlU11.D15G PROJECT'IUF.NI'IPIG11'II)N 27442
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
-e w UNIT# LOTH IS
of4pl PHONE: NTRAy4 OR, NA LIC NO: NC
Z ' Oc ll' w CONTROLN
ARCHI I ECI'/ENGINEER: LICNO ADDRES
WS
„, iJ e
CONTACT: PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLDG ELECT PLUMB 3*1 MSCI
PERMIT ISSUANCE S_T�_I/�_
LICENSEDtatICONTRACTOR'SDnsodCh TION APPLIANCES-RESIDENTIAL TOB DES IPfION
1402 Thereby affirmthatl 3 ofth Busised ness and
Pponsrofessions
(commencing with �� e
ts100 Section 1tMX))of Division 3 of the Business and Pofcssians Cak,end my license is in PANELS h 2 rP+O
QVF fu 11 force and cIf
Nz�V� I.icensc Clues Lic.# UP TO 200 AMPS -
Qy Date Commit 201-IOW AMPS Y "l;"♦ [�
>�yZ A CIIITIiCI-S D13C1 A'TION OVER IWO AMPS
SQ.IT.Il.00R AREA $/SQ.IT.
O Z—❑ 1 undemmd mY plans shall be med as public records.
Fyf-j SIGNS ELECTRICAL
Licensed Professional
'KQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOyu I hereby affirm Nat 1 am exempt from the Cimmann's License Law for the
In3 a y following mason.Section 7031.5,Business and P ifessions Coda Any city or county TEMP.METER OR POLE INST.
t��; which raryiresn Pennil In construct,ober,improve mulish,or repair any strucmrc
cgprior to it.iusame.tila,"aires theant pplicaach mliuo0leam
signedetemem POWER DEVICES
ty K 0O that he is licensed pursuant to the finalist of the Cant non's License Law(Chapter
p'Ko(Ey 9(commencing with Section 701 ivislon3oftheB i and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefm the basis for the alleged xemption.Any sampeviolation of OItD,LTS-SWITCHES-FlXTURES /
FZa Section 1031.5 by an foramotsnbjectsthee licanmoacivilpeoalt f `� QO
Q
nal mom than undreddo11ers(S500). NEW RESIDdNI'IAL ELECfR5 .FT. L
0 El ],a w eridlhcproperty.ormyemployeeswilhwagcs theinsolecompensation, Q STORIES TYPE CONSTRUCTION
E:22 willdath work,and the sumeture isnm intemedoroffend for. e(Sec.1044,Business
and Probe ions Cala The Cont et r Law docs no pply to an owner of
,property se Wildsmimnovesthe $ wl doessuchwor mseIgh his
cmplo) es,providedt esti mcrosate edoroffertdforsale.IL OCC GROUP RIS.UNITS
however,Nc oil ing_an” v -t is sold withi m earofrompletion,tbeowner- .T
builder willl lv Jr. ving that h not build arimprove her purpose of
sale)' e e Y. PLUMBING PERM FEE FLOOD ZONE
❑ films a?t c pcny,am ex amelycontmcting with liansW comrecmrsm APN
construct the roject c.11004, sloes,and Pofasions Coda)The Cnntrvcic"
Licenm Luw< nm apply Ina ermpropenywho buildsaimproves lhercon,and PERMIT ISS CE
.mUmmans.such Pmi witheconuaaot(s)licensedPursuantmthe Convacto"
License Law. ALTER-DRAT V) ER(E FEE SUMMARY
C] 1 mer use I er Sec. B&P C for This realm BACK FLOW PCT.DErICF, 0 SIDE P s
SANITARY YN
Owner - Date DRAINS OOT'A .COND. RECEIPT'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ I herebyafliml that l have acenificate ofconsennoself-insure,orae tcaleofFlXTURES-P P RECEIPT#
WorkersCompensation Insurance or a cenificd cap,thereof(!aJSW.La .)which PARK TEF, y N
cover,all employee's under this Urain. GAS-EA.SY 'M- .4 OUTLETS ECEIPI'
Policy#
BU 1 G VI NFEES
Company GAS-EA.S . CM- (EA) PLANCHECK Flit
❑ Cenilied copy is hereby famished.
❑ Certillud copy is fled wish thecity inspeainn division. GREA." STRL WASTE INTERCEPTOR `
GRADING
CGRDFICATEOF EXEMPTION FROM WORKERS' GREASE AP SOILS
COMPENSATION INSURANCE
(This section need not be campleled if Ne permit is for one hundreddullars(SIM) SEWER- NITARY-STORM EA.2WFT. ENER
m Ices.)
I cenify that in the performance of the work for which this permit is issued.I shall -
AT17R HEATER /ELECI'R
not employ any pethmn o manner soy g c e y{j rat the Worked PAID
z Compensation fCalifi . Da¢ WATER SYSTEM[MIITING Date Receipt If
O APp1lLant i fff���
z NOTICETO AT I CANT If,afro ng this nificate mExemption,you should NEW RESIDENTIAL PLMB. SQ.PC TOTAL:
f•" C") became subject to the Workels Com tion provisions of the Labor Code,you must
7 forthwith comply with such provisions or his Permit shal l he deemed revoked. BUILDINGFEE
4 CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of
U O the work far which l his permit is Maud Sco.3097,Civ.C.) T ELECTRIC FEE
Leaders Name
oV Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 cenn',that I have read this application and slam that the above information is MECHANICAL FEE
G c set. lugreno ntmply with all city and courtly oNinames and sate laws relating to PERMIT ISSUANCE
F" rA buildingeommuction.and hereby authonae representatives oflhis city to at upon Ne CONSTRUCTION TAX
V Z move-mentioned ptopcny for inspection puri ALTER OR ADD TO MECII.
(We)agree tit save,indemnify and keep harmless the City of Cupertino against
Iiabilitiel,judgments.coslsand expenses which may in any wryaceme against said City AIR HANDLING UNIT(TO 10,01)CFM)
in consequence of the granting of this Permit.
AIR HANDLING UNIT(OVER 10,IX0 CFM)
Signature of ApplicanisComiacior Date EXHAUST HOOD(W/DUCp
PAID
1 IAZARDOUS MATERIALS DISCLOSURE I lE,TING UNIT(TO I W,OW BTU) Date R eipt#
Will the applicant or(uwre building occupant store or handle hevrdous material HEATING UNIT(OVER 100,fI008TU) Trypq{,:
as defined by the Cu 1mW Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(.)'/
1:1 Yes 0 N VENTILATION I-AN(SINGLE RESIDI
ISSUANCE DATE _
Willthea IiamorfutumWildin encu tlO1LER-COMP(311PORIW.OWBTU) F Md
• PP 6 pemuse eq .Air tQ ality Mwhichemil �.
hvanlous min contaminants ss define)by the Bay Area Air Quality Managcmem BOILER 100,000 BTU)
DistneR NAR 7n
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. �l /079
1 have read the havNous materials�uia merts under Chapin 6.95 of the 5
Culifamis 11edlh&Safety Cale,Sections 25505,25533 and 25534. 1 underannd d a C/i r UC
ifthebuilJingdoes Icumently bavicelenant that it is my respomibilitymnalifyNe �VCC rr r r
oI the req i meats which uv be met prior to issuance of is Certificate of
Ox nmhonnM agent - Date TO ISSUED BY:
OFFICE