27428 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO B 1.Ol i5- Licu"RITATI
BUILDING DIVISION APPLICATION/PERMIT PING PRODBING -MECHANICAL
BUILDING IBOJECI'IDEN'TIEICA'1'ION
PERMITNO.
I 27428 7 4 n Q
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BUILDING AIIDRBSS: L�' /L.��pp/q)�� /l AID if' - �J
lC.
SANITARY NO.
APPLICATION SUHMI'ITAL DATEJ
p`i a
UvvNIT# LOT# 7"'1QOrJ 3
2q-\-�—
OWN RSNAME: PHONE:
O M Z
CO ACTOR'S NAME: -r 2,00
nnW /,/ `4 L1t7r
NIC
CONI ROLN
\RCHH'EC/ENGINEER: LIC NO:
AD ESS;
'orrrncr: PHONE:
Q.LECI'RIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PE3RM1'f ISSUANCELICENSED
'
CONTRACTOR'S DECLARATION
lhembyaffrmthat l am licensed underprovisions of Chapter9(commencingwith
Section 7000)ofDivision 3ofihe Businessand Protato... Cale,amd my license is in
fuc na end ether.
Claret Class LIc.M b T i
APPLIANCES - RESIDENTIAL.
PANELS
DP T0200AMPS
yZ
100
Ut
�izw
1011DHSCRIPI'ION
A may, a
{"Ijr,}Iplr\`.}a-
Q y
'yZ
D Contractor
AR, ITECT'S DECLARATION
I unJemm�d my plans shall he used as public rtcoNs.
201 - I IKKI AMPS
OVER IWB AMPS
SQ. FT. FLOOR AREA
$/SQ.fT.
SIGNS 131.EC'I'FOCAL
5 J
J
License) Professional
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F
0
m
Y�
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o�
❑,�
ZQ
OWNER -BUILDER DECLARATION
I hereby off ran that 1 um exempt font Comment, the Comme, License Law for the
fallowing larval. (Section 7031.5, Business and Prefessinns Code: Any city or county
which requires n permit to eonstmct, ager, improve, demolish, m repair my structure
prior in its issuance, also requires the applicantfor such permit o file a signed statement
that he is licensed Pursuant to the provisions of the Contractor's License Law(Chapter
9(mmmenein with Section 7000) of Division 3 of the Business and Professions Code
enip )
orlhoat hc 131.5 by nyappomand the basPermitonheaseged exemption. Any violation of
nvndorricnntfm$500). Permit subjects @e upplicmno acivil penaltyof
Seclot
SPECIAL CIRCUIT/MISC.
TEMP. METER OR PULE INST.
POWER DEVICES
SWIMMING POOL BLE.C'1'RIC
VALUA}'ION_
/lRrl✓tel
OUTLETS - SWITCHES - FUTURES
33
nim7031.5ve
10 atm rofthe rood yllarmyemp.
n❑ prnpeny.ormyemployaswith wagesastbeirsoleampcnsaion,
will o lie w rk,ande
and, cimefacili id dos ss
e (Seaapply
NEW RHSIUFN'TIAL ELIiCTR S .PI'.
—SQ.FT.
'TYPE CONSTRUCTION
professions The
and Professions CWe: The Cnntructnrs License Lew time not apply to nn owner of
stem kende Law not to owner of
pmpeny who builds orimprovesthereon, andwhadoesswab work hinnmfed throughhis
not trawler If.
ed
employees,provior thatimprovement
mehvement
OCC, GROUP
RIS. UNITS
however, m is within east sumpleered
erwill avec a burden powinlsheuthe idnet build rimproetiom,theowmer-
hale.). will have the burden of proving that he did not builder improve for purpose of
t^
QTY. ,PLUMBING PEItMI'F FEE
❑ I, asownerofthe progeny,nmcxclusivelyconumtingwithlicensed ronnncmrm
FLOOD ZONE
ANN
consomLicense the project (Sec. oann Business and Professions or imp ave Comhacmr'e
wM1modpsorintprovee
Licensetawdoesnot apply toawith
\ PERMIT ISSUANCE
Conarmand
acafproperry
who cantadsfor such pmjects withecontredor(s)Iicrnsedpursuanna Ne Comnemr'a
License Law.
ALTER-DRA WATER (EA)IaEF.
SUMMARY
❑ 1 nm eumpt under Sec. , ❑ & P C for this reason
BACK M PROIEM. EVICE
UqSIDE EF,b
Owner Data
DRAIN-
DRAIN FLOOR, ROOF AR COND.
SANITARY Y N
WORKMAN COMPCNSA'fION DECLARATION
❑ Ihertby a(Rnn them heveacenifcete of conunno self -insure. oro cenifcate of
Worker'Comparsation Insurance or a certified copy thereof(Sce. 3900, Lab C.) which
SCHOOLTAX Y N
RECEIPT
PIX RES-PF.R TRAP15
PARK GEE Y N
AS -FA. SY INC.40t/T1.FT5
covers all employee's under his permit.
Policy M
REC131PI'A
BUILDING DIVISION FEES
Company
GAS - EA. SW OVE 4 FA)
PLANCHECK FEE
❑ Caddied copy is hereby furnished.
CR[iASE/1 L A RC OR
GRADING ITE
ElCmifed copy is fled with Ne city inspection division.
CERTIFICATEOFEXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
GREASE
SOILS FEE
SEWE SA IT - RM EA. 2 FT.
ENERGY PEE
(this section need not he completed if Ne permit is for one hundred dollars( )
or less.)
EA ENE'/ELECT
I certify that in the performance of the work for which this permit is Liss ,l shall
s
am employ my person in any m me
o as to becosubject to in Worker'
P VD
MITREATING
Z
0
Ln
Compensation Lawsof Califomia Date
Applicant
Date ReceiptM
NOTICFTOAPPI.ICANT:1[nflfr making this cenifcate of Exemption, Yau shoo
becamembjecno the Workers Compensation provisionsofthe Your Code,you must
NEW RESID AL PLMB. SQ. FT.
O'IAL:
5
forthwith comply with such provixlons of this pertvil shall be domed revoked.
BUILDING FEE
SmSMICFEE
Q
CONS !RUCTION LENDING AGENCY
1 hereby uffirn that there is n constmction IenJing agency falba performance of
the work for which this permit is issued (Sea 3097, Civ. C.)
ELE
U
4
z
Lenders Name
Lender's Address
QTY.,' MECHANICALPE•RMIT FEF;',
Pwh FEF
I certify Nat I have read this application anab
d state that the ove information is
correct. I ngrce to comply with all city and county ordinances and state lows relatingmPERMI'1'ISSUANCE
huilding construction, and hereby outflow repmumatives of this city to enter upon the
u arectncito edl rapenyforic,peedonp
pueet.
MECHANIC .PEE
ALIERORADDTOMFCH.
CONSTRI ION TAX
e) agree tin save, indemnify and keep harmless the City of Canadian against
li nies,judgmeno,costs andexpenses whichoory in my way accrue against said City
AIR HANDLING UNIT LI 010,000 CFM)
c tscyucnceof the granting ofthis Permit.
I
' V— LData
AIR HANDLING UNIT COVER 10,010 CFM)
St ammo Applicant/Comm or
EXHAUST HOOD(WNUM)
HEATING UNIT (TO 1011,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Receipt g
Will the applicant or future building occupant store or handle hazamleus material
us defined by the Cupenima Municipal Code. Chapter 9.12. and the Health and Safety
HEATING UNIT (OVER I WJW BTU)
;D,ta
A.:
Cede, Section 25532(e)'1
El Yes ❑ No
VENTILATION FAN (SINGLE RESID)
Will the epplicanmrfuwre buildingoccupmtuseeyuipmemordeviceswhichemit
hvardess it cannonballs as claimed by the Bay Area Air Quality Management
District'I
❑Yes 0 N
BOILER - COMP QHP OR 100,000 BTU)
NCE D
BOILER -COMP (OVER 100.000 BTU)
NEW RISIUENTIAL MECH. SQ. PT.s
aza
I have read the hrdous materials requirements under Chapter 6.95 of the
California I lealth & Salary Code, Sections 25505, 25533 and 25534. 1 imcfan end that
`U�`h'/ ,1
N
Bribe building does not c.early have a boom. Brad it is my responsibility to ratify the
occupant of the requirements which must be mel prior to issuance of a Certificate of
Occupancy.
ISSUED BY:
Owner or authorized agent Data
TOTAL:
OFFICE