27996 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HDILDIMP-RI.FZ I KJCAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICA I. /\�J /�/�Y6/\
BUILDING DIVISION BUILDING.PROJEC'IT DENT IFICA'TION' L I BVI V4
IWILDINO ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
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IOWNGR.'NAMFTR
j Adak - I}pyE: ^ ONAfSp 'SN M': LOTx LIC NO:
fV1 l`+It�J x0 /V*1 NIC COMAOLk
CIII'11iC1'/ENGINEIiR: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
NftNCy FAN QTY. ELECTRIC PERMIT FEE
BLDG !LI;CT PLU M�eC1Ix
PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL )OB DESCRIPTION
psZ lhertbyamam li
ffirthaticenudom
ualerprovsiofClut(commencing with
a00 Section 9001BOf Divison 3nfthe Businesaand Profession,Code.andmy license is in PANELS
CIS full force and effect. t
FVU UP T021#fAMI'S �,, ���
lit( Dole ,Class Circ t \\VV
w Q p• Dae Convenor 2(11-IIXp AMPS �\ \
7 z SQ.FT.FLOOR AREA E/SQ.Il'.
L0,— ARCM IN,used
DECLARATION OVER 1000 AMPS k JZ_❑ 1 undersmnd mY plans shall be read as public records. SIGNS ELECTRICALLlccnsul Profssional
OWNER-exempt!RDECLARAI'ION SPECIAL CIRCUIT/MISC.KaU I hereby amrtn mw 1 am exempt front me Commnnr's License Luw fnr the
awt following reason(Section 2031.5,Business and Professions Cade:Any city or countyTEMP.METER OR PoLE INST.which requires a Permit to construct,alter,improve,demolish,m repair any sweture poor to its issuance.also requires the applicantfor such Permitto rile a signed iedement POWERDEVICFS46'60 shut he isl er ed porswtnt l,,,be pro—rorenr rhe Contractor.,License Law(chapter SWIMMING POOL ELECTRICo�' 9(comntcncing with Section YUUU)of Division 3of the Businossund Pafcsstmu Cudc) r VALUATION
KomSection731.5 by uberefromand the permi,ortheallegedexcmpion.Any violation ��wQ�orthate he isLempt threfromtnfora basisfrthecu theexemAnyOUTLETS-SWITCHES-FlXTURFS _ L/
W 0 not more than five hundred Jolters(ESW). - NEWRESIDPNTIALELECTR SQ.FT.
W�m ❑ I,mownerofthepropcny,ormyempbY¢s withwageauaMirsolecompenwtio6 r STORIES TYPE.CONSTRUCTION
W
will do the work,and the structure is not intended oroffeird forsele(See.9M4,Bminexn
and Professions Code:The Contractors License Law does not apply to an owner of
property tube builds or impmva thereon,and tubo Jces such work himself or through his
tun emPloyas.provided thvtsuch impmvcntcneae not inlvnJcdorofRred formk.
If. OCC GROUP RFS.UNITS
however.the buildingor improvement is sold within one ymrofcompletion.the owner- T /
builder will have the burden of proving that he did not build or improve for pur,%c of
* I,ns owner of the property,am exduaively conOccurred,Occurred,with licenced commit.commit.to QTY. PLUMBING PERMIT FEE IyAOD ZONE. APN
'mtsu the project(See.70f4.Business and Professions Code:)The Comracmrs
Liam lawdoested apply loan owncrofpmperty whobuilds m inprmand
ovesmenn, PERMIT ISSUANC[i
whocommns foraach projects withacontractor(s)licensed pumuant to the Contowtx`s ALTER-DRAIN&VENT-WATER(G7 FEE SUMMARY
License law.
❑ I.,it exempt audit,Sec. ,B&P C for di,reason BACKFLOW PROTECT.DEVICE :SNI:I I I:S
SANITARY YN
Owner Date RECEIPT#
' DRAINS-R.1PoR.ROOF.ARFA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
1 hereby affirm that 1 have a certificate of consent m self-imme,m a certificate of ftECEIYT p
7 XTURES-PF.R TRAP
lockers'Compcusation losurunceoro eenifed copythereof(Seo.3900,Lab C.)which PARK PEE Y N
all employee's under this permit. GAS-EA.SYSTEM-1 INC.Y OUTLETS CEI 1'M
covers# BUILD D ION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK
❑ Certifed copy is hereby famished.
❑ Certified copy is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEL
COMPENSATION INSURANCE
(This section need am bromandcted ifthe permit is forone hundred dollars THIRD) SEWER-SANITARY-STORM E.A.NART. ENERGY FEE `
ser Ices.)
I cenifydan in the performance of me work for which this permit is issued,Ishall WATER fIEiiTF-R W/VENT/F.LECTR
not ems
ploy any person In any nocaut t as to ec
bome subject to the Workers PAID
Compenution Lawsof Culifomia. DateWATER SYSTNM/IRIIIING Date Receipt
O z Applicant
z � NOTIC[TO APPLICANT:ILahcr making thi,Certificme of Exemption.you should NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
f" .�. become subject to me Workers Compensation provisionsefthe labor Code,you must
funhwith anmply with such provisions onhis permit shall be deemed revoked BUILDING FEE _.�
7
d [� CONSTRUCTION LENDING AGENCY SEISMIC IEE
z I hereby affimt that them is a convection lending agency for the performance of ELECTRIC FEE
U O the work for which this permit is issued(See.31197.Civ.C.)
Lenders Name PLUMBING FEE F Lenderx Address Q'I'Y. MECHANICAL PER IT.
U I certify thm 1 have revel this application and state that the above amounted is MECHANICAL FEE
correct, l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
nve �-
building construction,and hereby authuti
orize reprevenvesofidus city reenter upon the
U zCONSTRUCTION TAX
above-mentioned pmpeny(or inspection puryous. ALTER OR ADU TO MECfI.
(We)agree to save,indemnify no cep harmless the City of Cupertino against
liabiliilcs.jndgmenu,ensu mA ex nshidumyinanywayaccrua against said City AIR HANDLING UNIT(TO 10.000 CFM)
in conseq cc of egra tin of ip, ii
AIR HANDLING UNIT(OVER JO."CFM)
Signa pplicanUComracmr Dae EXHAUST HOOD(W/DU(M PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Data Receipt#
ill the applicant or future building occupant store or handle herarcious material TOTAL
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety I HEATING UNIT(OVER i W,(gp BTU)
Cale,Section 25532(,)? VENTILATION FAN(SINGLE RESID)
❑Yea El No
BOILER-COMP(31IPOR IM."BTU) ISSUAN EDppATE
Will the applicant or future builJingoccupanmueyaipment ordevicn which emit q '
doses air crmtaminan,as defaW 110 by the Bay Area Air Quality Management BOILER 100,0BTU)
cl 1 /99qf�
13 Yes 11 No NEW RESIDFIAL MECH.—SQ.IT. JUN (J 0� 1
I have read the hitmmerlaN requirements under Chapter 6.95 of the v
Calif orit.[Icahn&Safety Code,Sections 25505.25533and 25534. 1 and entund that `•j(f
ifthe building does not currently have a tenant,that it is my responsibility to notify me
occupant of the recuiameaca which must be met prim to issuance of a Certificate of -
Occupancy.
Owner ser nwhOriud ngcm Date ISSUED BY:
OFFICE