27910 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BITI1.UIhb-ELEG RI AL FERMI'(NO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 27910
BUILDING PROJECT UIBN'1IFICATION
1 . INADADDRESS: SANITARY NO. APPLICATIONTT
LISUBMITTAL TE
s DA
1 1/^ ,t T g� UNIT# t LOT# 11e �J
DW ?RS NAM I?: PIIONE:r� (�>�3 CO ACTON'S#AMI?: LIC NO:
w.� N/C CONTROL N
r N III'ILCf?NGINf;E,R _ !IC NO: O ISS: 46a_a. x /v ❑
1[Ml -0•1- C.
CONTACT; PUONE: o BUILDING PERMIT INFO
QTY. LLEC1'RIC PERMIT' � PI?[;
R0 EL PLUMB
N YTI• B 04 PERMIT ISSUANCE �LUMBB
LIC ENSEDCONTRnderpmSDmofChaTION APPLIANCES-RFSIDFMIAI. 1py DP RI�
p;z lherebyaffrmtrion3osum fthe Bulocitimad riowoons Cae, nd mmecense with f4•+f�gV\�yj
00❑ Section]OW)af DivisionJof rhe Businen end professions Code,end my license is in PANELS
p;W U lid.force
b'<u License CWss LiaN. g-3Gx� UP T021HIAMPS "
m6y Dram Cnmm 201-I1N1f1AMPS
20HLARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.let-
1
T
O'L O 1 understand my plans shell be,used so public records. OVER IOW AMPS
P oo�:m SIGNS ELECTRICAL
<yF,� Licensed Pmfeasi...I
�4• OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
ippi55,,O4Uf— I hereby affirm that I am exempt from the Comment.License Law for the
u+3pooa following reason.(Section 7031.5,Business and Pnfescumms Code:Any city or county TEMP.METER OR POLE INST.
' m.] which requires a permit to construct,alma improve,demolish,or repair any structure
C Q� prior to its issuance,vlsim,drestheapplicant for such permit,,file.signed stetement POWI?R DEVICES
ty.. O that he is licensed punuunno the provision of the Cantmctors Liana Law(Chepter
44Q� 9(coomencing with Section]OW)of Division 3 afire Bmarmisand Profession Cod SWIMMING POOL ELECTRIC VALUATION
y _y or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
i Section]031.5 by an OUTLETS-SWITCHES-FIXTURES 1 D G
3Qydredd larv(Spennit auhjects the applicunnn.civil penalty of ` OO
urn more then five hundred dollars(SSIXp.
� � ❑ I,usownenffthC propcny,ormy employroswith wagesustheir nolecompensmion, NEW NESIpI?N'fIAI.F.LF,CI'N _SQ.FT. STORIES TYPE CONST'NUC'I'ION
will do thewark,and the strucmre isnot imendW,roffiamd forrale(See RW4,Business - -
.ad Profenimul Calc:The Contractors Liana law does not apply I an owner of
property whmbuildsorimpravesduces. ,and whadoessuch work himselfiroda ughhia
employeesilding rimprsvchimpnvemeitsaonm iamnfoompl&red theownr. OCC.GROUP NES.UNITS
however,illhathe vl the burden of proernving that
he dhinonmymaror improve for
treowner-
builder will have the harden of proving that he Aid not buil)or improve for purpose„(
rola).
❑ I,as ownenff die propeny,am exclusively cantrudingwith licensed contractors to QTY PLUMBING PERMIT PEC FLOOD ZONE AI'N
canxrncl the prnjen(Sec.]U44,Business and Profession Culex)The Contrecmr'e
License Law does not apply to an owner ofpropeny who builds or improves thereoc'mal PERMIT ISSUANCE
whocantmcmfursuchpmjaewiNecon"cior(s)lirenudpunua Rothe Conamemr's ALTER-DRAIN&VENT'-WATGR(PA)
License law. d FEE SUMMARY
❑ I am exempt under Sec. p&P C for this reason BACK FLOW PROTECT.DEVICI? SANITARY Y CS N
do.ter Dune DRAINS-FLOOR,ROOF EA,COND. RECF:IIT#
WORKMAN COMPENSATION DECLANA'I'ION SCHOOL TAX Y_N
❑ hercbyaffirm that lhave acenifoute of wnsem to self-insum,or acenifcute of FIXTURES PP P IUCEIPI'#
Wmkerc Compenvtionlnsurence ora cenifiedcopy thercof(Sec.Jg00.Wb CJ which PARK FEE YN
coversell employce's under this permit. GAS .SYSTEM-1 INC.4 OUILLTS RECEIPT#
Policy ll BUILDING DIVISION FEES
-- Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifuedcopyix1mm1byfumish4
❑ Cerriful copy it 0l.J with the city inspection division. GREASE/INDIIS'1'RLWASTRIN'II?RCEPIOR GRADING FEE
CERTIFICATE OF EXIIMPTION FROM WORKERS' GREASE TRAP P SOILS PEE
COMPENSATION INSURANCE.
Tilde section nod not he completed ifthe pumit is forone hundred dol (SIW) SEWER-SAN R T MHA.200 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permh is in d,toroth A . W/VLNTp'1.
not employ any person m any manner,m as o the Workero pglp
Compensation Law x f ia: D I ?R SYSTHM/fREA 1 O Dme Rcccipt#
O z Applica t
Z Q NOTICE TO APPLICAM':If,after makingthis Cen m.mof Caemption,yo should F. RILS I! IAL^ S TOTAL:
r h become subjecunthe tankers Compenmtinn provision of the lsMrCode,y mus -
Ing forthwith comply with such previsions or this Permit shall be dccmed invoked. BUILDING E 1 ��
a [� CONSTRUCTION LENDING AGENCY SEISMI
l hereby nffrm tbxnhere iso construction lending agency for the performan, of
O the work for which tbislxrmlt is issued(Sea.3097,Civ.C.) - \
Lks Lenders Name
Q U hander's Address Q7'Y. MIiC LAICAL PI?EMIT FEE TNG FF.E
1 certify that I have read Nis application and state that the above in(ormmian is
L1a c rrect.le to comply with all cit and animations andsmm laws acatin ur PERMI' UANCC MI:' ICAL FEE
gree pYwi yon Y B
V � huildingcmetmction,andherebyauthodnmpmsenmtivesofthia Cityocnterupoathe CONSTRUCTION TA%
y aWve-merninned Property for inspection purposes. ALT ER OR ADD TO MECH.
F7 (We)agree m save,indemnify and keep harmless the City of Cupertino uguinst
liabililics,judgmems,costs end expenses which may in any wayaceruevgains,said City AIR HANDLING UNIT(TO 10,00X)Cl'M)
nsequcnce oft of gof�thi�s ypermit. as
//L /Rr, AIRHANDLING UNIT(OVER 10,0000-11)Signature of Appliam/Camrncmr"L 77 Date EXHAUST I IGOD(W/DUCp
PAID
HAZARDOUS MAT17RIALS DISCLOSURE HEATING UNIT(TO 10b."BT U) Date Receipt#
Will the applicant or future building occupant sore or handle hmnNooe material fIPATING UNI'I'(OVER 100,000 BTU) TOTAL:
n..defined by the CuPcn ioo Municipal Gr1e,Chapter 9.12,and the Health and Safety
Code,Section 25532(q:'
❑Vex 13 No VENTILATION FAN(SINGLE REMO)
BOILER-COMP(3HP OR IW”BTU) ISSUANCE TE
Will Neepplicant or fuwre buildingaccupam uuequipmem nrdevicu whichemit . D
huxardom air mntaminenu as defined by the Bay Ara Air Quality Management BOILER-COMP(OVER 100.0010ITT U) P A B
District?
❑Yes ❑No - NEW RHSIDHN'I'IA[,MECH. SQ.FT. .APR 7
1 have read the hexerdous materials requirements under Chapter 6.95 of th
nde " Q 1995
oe
Califoa l le th&Safcty Cade,Sxtiona 2.5505,25533 and 8534. 1 undersand that ^/`
ifthcbuildingdsnane
t emonaly haveamnt.that it is my responsibility in mainly the Ory r
occupant of the requirements which must Po met prior o issuance of Cenifiam of Ur'C
Occupancy.
Owner or authnrimd ngcm Dale T0'1 ISSUED BY:
OFFICE