27119 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B,oli'mi,LILLLTRTCO, PERMIT N[77777777O. 27119
�7 1 1 �a
APPLICATION/PERMIT PLUMBING.-MECHANICAL 'LJ �IJJ
BUILDING DIVISION NUILUING PROJECT IDENTIFICATION
[OWNER
UILDING ADDRP_SS SANITARY NO. APPLICATION SUBMITTAL DATE
esn
O poo", / UNIT, LOTp V qLt
� � ���� PHONE: CONI' A 'OR'S NAME: ,.-a NIC_Ift VVVV'GNI' Ol.a
ARCHITECI'/ENGINEER: LIE-NO: ADDRESS: �!l/ / ❑
COMPAQ: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT NEE
BLDG ELF. P.UM F.0 I
PERMR ISSUANCE �G.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I� w.i PPP���KKK��,
Ihertb ffnmsion 3 of
the
sed under oche t 9nd(commencing with �l?vvs
no:z yin provisionso per g
t+r00 Seetiao?(yJO)of UivisionJof the Bu..+toes,and Professions Cade,and my licumu is in PANELS
W F
License
Tarte and cffst. -3 -
ocLW Date Class�Conio J L UP TO IDOAMPS
y=y Date Commcior - 201-1000 AMPS SQ.IT.FLOOR AR EA 1/SQ.IT.
ZO vms'z ARCHU FCTS DECLARATION OVER 1000 AMPS
O Z—O I understand my plads,hall heaved!m public records.
r!L,F w SIGNS ELECTRICAL
Q $, Licensed Professional
�ow6 OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC, m 8
O e. I hereby uffon that 1 am exempt rema the Cantmcum's License Law for the r
to 3 W w following rcazon.(Section?031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which myuiacs a pemtit to ronstmet¢Iter,improve,demolish,ar acpair any swclurt � tl tl q� I� f,1
prior to its issuance,also acquires the applicant farauch permit file a signed smtemem POWER DEVICES I - l � ,�1 oet
I`Il./I' IYI CLQ— 7Pr.[i
ytEOO that he is licencedpursuanttotheprovisionsofthe Contractor's License Law(Chapter SWIMMING POOL ELECTRIC°i .0! 9(commencing with Section 7001af Division 3 o the Business and Professions Code) VALUATION
iALA
W M,,, or that he is exempt decrement and the basis for the alleged exemption.Any violation of OUTLETS-SWRCHES-FlXTURFS
F.ZQ Section]031.5 by any applicant for a permit subjecor the applicant m a civil penalty of
rSrS t more than rive hundred dollars(5500). NEW RESIDENTIAL ELECIR SQ.FT.
W
d❑ hasnwnerofihe properry.ormyemployees with wagesasiheirmlecompensadon. STORIES NPI:CONSTRUCTION
will dolor,work,and the structure is not intended oroffened for sale(Sec.?044,Business
and Profession Code:The Contractor's License Law does oat apply to an owner of
pmpemy whtbaidamsenprovestherton,add whadues such work himselfiethmughhis OCC.GROUP RES.UNI IS
employees.Providea prsaehimprovld within
yerodedeooffeed forsale.Ir.
however,thebuilding or improvement is sold a didn one year or improve
omm a fo,thpurpose
of TOTAL:
builder will have the burden of proving that he did not build or improve for puryase of
sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ hat-awnerofihe propenY�am exdusivelymntracming with licenud convectors to
commute the project(Sec.7144,Business end Professions Code:)The Co...,*.
Licemalawdoesnot apply torn ownerofpropeny who builds or impowe,themon,and PERMIT ISSUANCE
who cmnnmts forsueh projects with u eontraetogs)licensed pursuanuorhe Comervair's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
Liver,,Lew.
❑ 1 am exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FF.FS
SANITARY Y—N
—
Owner RAT DRAINS.FLOOR.ROOF,AREA.CORD. RF.CEIPTa
WORKMAN COediiNSAT10N DECLARATION SCHOOL TAX Y N
❑ Ihereby affimnthmnhave
rance anilica fica consent to self-insure,rc,or Lab C.)nic ofwhich FIXTURES-PER TRAP RECEIPI'a
Workers Cnmpensaion lnsumncemeanifed copy thereof(Sec.3tlW,Isb C.)which PARK FEE YN
cover,all employeds under Nis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS ftECEa
Policy X BUILDING DIVISSION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Ccniliedcopyiahercbyfumishel.
❑ Cenifed copy is filW with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF.
COMPENSATION INSURANCE
('Thisuctlon need nm he completed ifthe permit is for one hundred dollars(SlDA SEWER-SANI'T'ARY-STORM EA.20017. ENERGY FEE
or less.)
I ccnify that in the parrs,of the work for which his .I,is issued.I derf WATER BEATER W/VENTIELECUR
not employ any .an in any mariner so as to become subject to the Workers' PAID
Compcnxtionlawsof California. Date WATER SYSTEMiTRGTING Data Regi tx
O ,Z. Applies.,
Z2 NOTICE TO APPLICANT:If.,fat making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.I'L TOTAL;
F-' 0 becomeaubjecr to the Workers Compression provisions of firm Lothar Code,you must
a 7 forthwith comply with such provisions or this Permit shall be deemBUILDING FE
revoked.
Q CONSTRUCTION LENDING AGENCY SEISMIC I'1i
IL.7. z I hereby affirm that them is a construction Tending agency for the perfomnnce of TOTAL: FLECTRI
U 0 the work for which this permit is issued(Sec.30D.Civ.C.)
Lenders Name PL
u" F Lenders Address QTY. MECHANICAL PERMIT FEE
U U I ccnify that I have read this application and xwte that the,hove information is MCC IC LIEF;
11-) correct. Iagree mmmply with all city era county ordinances and state laws relatingm PERMIT ISSUANCE
F' bulldingronsirucrion,end herebyaurhonre reprtsentativesafthiscity memerepan the CONSTRUCTION fX
Vabove-mentioned property for inspection hapoxs. ALTER OR ADD TO MECH.
(We)agree to save.Indemnify and keep harmless the City of Cupertino against
lishilh1e. it'me
and cxTmns may in any way c against said City AIR HANDLING UNI'T'O010,000 CFM)
of tl m is J
fa / AIR HANDLING UNIT(OVER 10.00f1 CFM)
g amen&Applic.co Commctar Date EXHAUST HOOD(W/DUCI')
PAID
I IAPARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO hary)(1 BTU) 1alA Receipt a
Will the applicant in future building occupied store or harulle haraMous ma¢nal HEATING UNIT LOVER IOU.gp BTU) h4now 11 7-0
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(u)'I
0Yea 11 No VENTILATION FAN(SINGLE RESID)
Will theapplicantorfu umbuildinguecupani umequipmentordevienwhichemlt
BOILER-COMP(3HPOR 100,00D BTU) ISSU C DALE
81 haurdou,air contaminants as defined by the Bay Arco Air Quality Management BOILER-COMP(OVER 1ID,000 BTU) _
District?
❑Yes 11 No NEW RESIDENTIAL MECII. SQ.FT.
I have read the ha>ebous materials requirements under Chapmr 6.95 of the OCT u La
California Health lealth&Safety Code,Sections 25505,25533 and 25534.1 understand that V 1994
99/1
Urfa,bui Wing does.ot cumcntly haver tenant thin it is my resp risibility m notify the �6
—punt of the milmocamers which must he met prior to issuance of a Certificate of
Occupancy. CI It ur k..
Owner or aidoriiorl agcm Date TOTAL: ISSUED BY:
OFFICE