27618 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CiJPERTINO B 1 DIN.-E R AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27618
J C O
BUILDING DIVISION + ' BUILDING PROJECT IDENTIFICATION G o 8
BUILDING ADDRESS: UNIT# LOT# SANITARY NO. APPLICATION SUBMITTAL DATE
A�
l,-1 Ir9�
W ERS NAME: PHONE: NTRACTOWSNAMH: LIC NO:
_ NIC �CONNTTROL#
CHI'IECI'/ENG EER: LIC NO: �� ADDRESS: T ❑ � g9
1
COMPACT: PHONE: /, BUILDING PERMIT INEO
9/4 QTY. . _ - ELECTRIC PERMIT FEE
PERMIT I'SSUANCE BLDG, By PLUMB ECI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 103 DESCRIPTION
Matz I hereby affirm that l am licensed anderprovislonsmf Chapter9(commencing with
[s100 Section 7000)of Dlvtsi 3ofthe Bueiness and Professions Cale,end myliunse is in PANELS
Fa Zig fullnse Clad effect. G UP TO
<z License Class Llc.#
y<.� Dote Contractor 201-IWE AMPS
FyZ ARCHITECT'S DECLARATION SQ.FI'.FLOOR AR' $/SQ.FT.
cz—a OVER IWO AMPS
z c` — l understand my plans shall be used as public records. /
6i2 -""Ij Licensed Professional SIGNS ELECTRICAL
�wm< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. //{ ✓
LxOyU 1 hereby nrfirm that I am exempt from the Convectors License Lew Ter the �rD40
00'3 m ti following reason.(Section 7031.5,Business and Professions Code:Any city or county 'TEMP.METER OR POLE INST. J
which requires a Permit to construct,alter,improve,demolish,or repair any structure
gTprior to its issuance,also requires the applicant for such permit to file u signed statement POWER DEVICES
�<0 mat rte is hcemsW pnrsnanno me Prnvismns urine eommorora License caw(enamor
tr. SWIMMING POOL ELECTRIC
aWo 9(cummeociogwith Semion7TXq)ofDivision3opha Business and Professions Coda) VALUATIONQ
W❑y Seer.i he is exempt therefrom and the basis fonbe alleged exemption.Any violation of OUTLETS-SWIT ES- /� /� �� /
4 Secdion7 LS by any applicant fora petmitsubjects theapplociat to aced penaltyof FIXTURES T
ta pnot eflun EVChandrWd011um(SSW). NEW RESIDENTIAL BLECT SQ.FT.
1,asowneroftheproperty,ormyemployeeswithwagesastheireolewmpensetian, STORIES TYPE CONSTRUCTION
y wIT dothe work,and the structure isnot imcndedoroffered forsale(Sec.70cf4,Business
and Professions Cale:The Convacmt's License Law does not apply to an owner of
prepeny who huilds m improves thereon,end who does such work himself nr through his
own empleyeroprovided the,snchimprovemenrvirenotiutendedoroffeied battle,If, OCC.GROUP RES.UNITS
however,the building or improvement i,sold within one year of completion,meovace TOT
badgered]have the burden of pmving that he did not builder improve for purpose of
sole.) QTYe. v-PLUMBING PERMIT '*P PLOOD 20NE APN
❑ l as ownerof the property,amexcluevely contracting with licensed commercial. afy - 5.�
onsvuct the p,.jet,(Sec TIFL Bus hes,and Professions Code:)The Contractors PERMIT ISSUANCE
License Law does not apply morrow scrofpro wry who builm er improve,thereomanJ
Licennsese Lose whoawose [or eucM1 proJecds with eeonvacmge)Iluosed pursuantmthe Contractors
. ALTER-DRAIN&VENT-WATER(EA FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for This reason BACK FLOW PROTECT.DEVICE OUTSIDE FE
SANITARY Y N
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Iherebyaftlrtnthntlbavea ecra crane consuntoselFlnsure,er Iam C.)cme of RfiCfiIPTN
Workers'Compensmionivumnce OracettifiW copy thereof(Sec.3g04 LahCJ which FIXTURP.S-PP.R TRAP PARK FEE YN
covers all employee's under this permit. GAS-EA,SYSTEM-1 INC.4 OU9LETS RECEIPT#
Policy# BUILDING IIIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PEE
❑ Certified copy is heroby furnished.
P_e-�ified copy is filed with the city inspection division. GREASFANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
or less.)
I certify that in the performance of be work for which this Permit is issued.Isbell WATER HEATER W/VENDELECfR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensulloo Lawsnf Caliromia. Date WATER SYSTENUTREATING Doro Receipt#
Q Z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
q] become subject to the Worker's Compensation previsions of the Labor Code,you must
? forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FE O
W CONSTRUCTION LENDING AGENCY SEISMIC
z FEE
^a Ihereby affirm that there is a construction lending agency for the performance of TOTAL: ELF.
U O the work for which this permit is issued(Sec.3097,Co.C)
Lenders NameL
F Lender,Address - QTY.-4x tMECHANICAT7PERMIT ' "FEE P UM➢NG FEE
U I cert fy that 1 have read this application and state that the above information - ' I FR
>" a correct I agree to comply with all cry and county ordinances and stoic laws relaungm PERMIT ISSUANCE FII 1{rsq'
t , building construction,and hereby autheriu representatives ofthis city to enterupon the
U 4 above-mentioned property for inspection porpoises. ALTER OR ADD TO#CIL CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may In any way accrue against sold City AIR HANDLING UNIT(TO 1 o,OW CFM))
in consequence of the standing of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Dace EXHAUST HOOD(W/DULT) PAID
HAZARDOUS ATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt
Will the applicant or future (ding occupant store or handle hazardous material HEATING UNIT(OVER IBO,Wd BTU TOTAL:
as defined by[he Cupenin M icipal Code.Chapter 9.12,and the Health and Safety )
Code.Section 25532(a)7 VENTILATION FAN(SINGLE RPSID)
❑Yes No -+�•
WilltheaPPlicanlnrfuturehTi ngacupam use equipment ordevius which emit
BOILER-COMP(3HPORIOO,OWBTU) ISSUANCE DATE -
Adak
hcosenzu,air stars,nnot,as il
efired by the Bay
Area
Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District? PLANNER . P�OUIRED
ff�$
13 Yes No NEW RESIDENTIAL MECII. SQ.FT. f NCY
; .. ,
I haveread the hazardous mmuzials require ens az Chapter 6.95 of the PRIOR TO UA
_
Califomin Heahh&Safwy Cod Sections 25505 5533 d 25574. 1 understand Chad
if the 'ding Me tcure hav eman at I[Is responsibility Tn notify the
pit of o�utreme metpit issuanceofit Co nofi
tify
y , 4
end Dote TOTAL: ISSUED BY:
OFFICE