27858 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
6UILDIN(i-RIL1I RI AL PERMIT NO. [
�CI'I'Y IN CUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL 'raj 7 p Q
BUILDING DIVISION BUILDING PROJECT IDRN'r1FICA I[ON L 1 O v
BUILDINGAIIDRftiS: 4 SANITARY NO. APPWCATIOONNS�UBNd ITALALaDDAATI
2 V JL XV
UNITKLOT
µ S� NT/RACOIR'S✓NAtME: v LIC Q NO:, IC. � '44y.9 CONT�R�OLof
RCIIItiCf/IiNGINEER: LIC NO: DDRFSS:
AK— ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT PER BUILDING PERMIT INFO
BLDG 'CECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RESIDENTIAL
M=Z ' Ihcrebyaffirra lou lam licensed under provisinnsofChepter9(commrncingwith JOB DESCRIPTION
{ 00 Section)00f0of Division 3ofthe Businessnnd Professions Codc,andmylicenseism PANELS
o:w full force and effe / �{ �.�
FZ. License C7a l.i<.M b7 S' UP T02IX AMPS �Jt sd _
mQy Date // �Comractor �,�. 2(11-IIXNIAMPS
�� �'�'�/�
F'Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLUOR AREA VSQ.FT.
Z O'_Q 1 un cmane n I stall he used as public records.
OZ—� Q^�.YPans
FmFJ �a�i0 SIGNS ELECTRICAL
Q Y J License)I nJessional
hatI OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OCF 1 hereby affirm That am eeempt from the Contrsctmrs License Law for 0e
ux131+.y following renan..(Section]031.5.Businessnnd Professions Cade:Any city memory TEMP.METER OR POLEINST.
T—�06 which requires apconit to construct,:Jur.improve,demolish,or mpairany stratum
prim to its issuance.also requires the applicant for such Permit to rile a signed statement POWER DEVICES
'W<0 that he is licensed pursuant m the provisions most Commerce,License Law,(Chapter -
a4oT 9(counnareng with Section 7000)ofDivisin 13mlle nessnn
Busid Professions Code) SWIMMING POOL ELECTRIC VALUATION
,_,, .,that he isesempuhcrefromand thelasisfmtheallegedesempion.Anyviolationof OUTLETS-SWITCHES-FIXTURES
I—ZQ Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of
ASO not more than five hmWreJdollars(E5W). NIiW RESIDENTIAL ELECTR _SQ.FT.
r.'Fo ❑ 1. sownerofthepmpcny,ormyemploy withwagesastluirsolecompmation. STORIES TYPECONSTRUCf1O,
it, will do the work,and the stmemre lsndificadedorad'fered for sale(Sec.9044.Business
and Professions Cede:The Contmctoes License Law does not apply to an owner of
property whobuildsmimprovesth over.and whodoes such work himselforthrough his
onvocimployseni.provided that such improvements are nntintcnded oroffered forsele.If, OCC.GROUP RES.UNITS
however,the buildingor improvement is suld within one year of completion,the owner.
builder will have the burden of Waving that he did not build or improve her purpose of T r
sale.).
❑ I.mownerofthepropcny,amesclusivelyc.ntnaingwitalicenscdcontmctorstu QTY. PLUMBING PERMIT FEE FLOOU ZONE APN
construct the project(Sec.7IW4,Business and Professions Code:)The Contiachus
License Lawdoes not apply to aaownerofpmpeny whobudds or improves thereon and PERMIT ISSUANCE
whocbnuaa,formch projects widtncommetm(s)licensed IF....un the Convenor's AUTER VENT-WATER HIA)License Law. ,__, ) FEESUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason _ OUTSIDE PE
Owner Date - - SANITARY YN
"DRAINS.FLOOR.ROOF,AREA.GOND. RECEIPT'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ l hereby afford that l have a ceniGcate ornament rosclf.imme,macenlficate of RECEIPT
Workers'Com tion larmranceora cerrifed copy Ihereof(Sec.3800,Lab C FlXTIJRES-PER TRAP
pensa py )which PARK PEE YN
covers all employees antler this permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT'a
Pali<y M BUILDING DIVISION PEGS
Company GAS-PA.SYSTEM-OVER4 J PLANCHECK FEE
❑ Carifedeopyisherebymmisled.
❑ Certified copy is filed with the city inspection division. GREASE/INDUS9'RLWASTE TERCF
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSETRAP V SOILS PEE
COMPENSATION INSURANCE
(This section nod not IN,completed ifthe Permit is formic hundred dollars($100) SEWER-SANITARY-STORM F.A.2dat ENERGY FEE
or Icss.)
I certify thin in the performarmcofthe work for which this permit is issued,Ishall WATER HEATER W/VF.NT/ELECTR
not employ any person in any manner so as to become subject to the WorkersPAID
O z Compensation Lawsof Califomia. Dae WATER SYSTEM/TREATING Dine Rcreiplp
Applicant
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
rr V) become subjectto the Workers Compensation Compensation provisions of the Lad Code.you must
>
� forthwith comply with such provisions of this Permit shall be lamed revoked. BUILDING FEE
QJ a CONSTRUCT ION LENDING AGENCY SEISMIC FEE
7 Z I hereby affirm that there is a conservation lending agency for the performance of
V O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leaders Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that 1 have read this application and stale that the above information is
r� 0.
correct.I agree to comply with all city and county ordinances and ante laws relating to PERMIT ISSUANCE MECHANICAL FEE
F" bidding construction.and hereby aahoriza rapmscrounses ofthiscity to enter upon the
I..) Z drove-mentioned property for inspection purlarres. ALT ER OR ADD 9'D MECIL CONSTRUCTIONTAX
(We)agree to save,indemnify and kap harmless the City of Cupertino against
liabit ies,jodgmems.a sts wdexpenxswhich anyway accmeir,unnnaid City AIR HANDLING UNIT(TO 10.000 CFM)
a n.µue t --man"of
is permit.
3 I AIR HANDLING UNIT(OVER 10.000 CFM)
Sigwture I llcalpCon tm a Date EXHAUST HOOD(W/DUCp
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,(Xq BTU) Unm Receipt
Will the the Cupertino
Municipainum l Coi Canter 9.or huddle hazardousHeand Safety
HEATING UNIT 100.010 BTU)
al
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety TOTAL:
Code,Section 25532(n)P
ID Yes C1 No VENTILATION FAN(SINGLE RCSID)
BOILER-COMP(311P OR 100,000 BTU) ISSUANGF.DANE
Will tae appOcantorfmurcbe defined
by the ay Arco Aen Quality
Mourechemit l
hazardous air contaminants m defined by the Bey Area Air Quality Managetrtem BOILER-COMP(OVER 100,04)0 BTU) npsa
11R Yes ❑No NEW RESIDENTIAL MECH. SQ.PT. 24
I have rend the hazardous materials requirements under Chapter 6.95 of the r1995
California Health&Surety Code,Sections 25505,25533 and 25534. lunderstandthat Vr Lv
if the building does not currently have a tenant,that it is my responsibility to notify the rC�f bl
'cupant of the requirements which nmst M met prim to issuance of Cenifcae of
Occupancy.
Owner o.authorized agent Dem
TOTAL: ISSUED BY:
OFFICE
POST THIS CARD NEAR FRONT OF BUILDING
(-4TY 0 F-CA 1 PF R FINO R17,11 IN,I In.
11011,10INI: RUIIMINGPROIU
JCi IDEN11FICAIMN
Ili 11.116(iAllil"I'sS S\NI I ARI !`,M11A %]I($.\skil"Ilt AIJ
YNf kSNA\lt NO
C(JNIRA(-IOR SANW IM:N
aMI e. NIC
!,I: I CIjI11CJ.NI.I.R 1.11 No. ADDRIESS
El
IN511FIC FIONS DA'11- INSPEC INSPECTIONRLCORD BUILDING PERMH INFO
IiI.IX; Fuerr PLIAM 11111,
NOT111 ALL GRADING AND DRAINAGE 1:1 El 0 El
SHALL BE INSTALLED TO COMPLY WITH 1011DESCRI1,110,
THE APPROVED PLANS AND CITY OF
PAD/SF.FBACK-( 1:10"
CU131-RTINO STANDARDS.
GARAGE SLAHS/PREGUNH F I I
IN)URNOCONCREM UNFFILABOVE HAS BEEN SIGNED INSPECTION SPECIAL INSPF-CTION A 11:
Ij\tDl',R(;R()UNrD/SI-AB I REOILARD) D
PLUMMING
1:1LI701RICAL
DONOI'MUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
PI-I—\MIN(-;
MECHANICAL
FLECI'RICAL
FRAMING VENTS
INSULATION
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
-ROOF SHFA rH/DlAPHRAM
PLUNIRING
'I URS&SHOWER PAN
MECHANICAL
• ELECTR ICA L/POOL BOND
f7RA,\IIN'C;/S I-AIRS/E.EGRESS
INSULA 1'10,N/VEN-1 ILATION
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
INTIMUR Sl IFAk/i 101-1)DOWN
17 N iT-R[OR S I IFA R/I I OL 1)DOWN
Sl fI:fd(lR()C&K/Sf H-T I'ROCK Sill"
FYI ERIOR I-A"I%l ,H/
W-SCREEN
SHOWER LATH
NOTAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
SCRATICI I COAT
SEVER/WATER
I*E%11'.)RARY APPROVALS
III'll-DING
FL17C I'k ICAI,
GAS
FINALS
GAS I EST
(;k..\])[:
FIRE PPROVED FOR OCC
I I AN 1)1 CA P I '110 ARRAi GE INSPI!- ISSIJANCI:Mij:
CALU P\1 I
I R I C A ./F IN 1:RMY
2SX44145 MONDAY TO FRIDAY 24 HOURS
BEFORE REQUIRED INSPECTION, JOB AD-
DRESS AND PL%RNII1 If ARE NEEDED WHEN
NIECHANI( AL/i!N191W31' PHONING.
-
NO IT RSOMS)Sl IALL PF R FORM WORK ON
'THIS JOB SITE. WITHOUT WORKER'S
OCCUPANCY OF BUILDING IS NOT PERMITTED C ENSATION INSURANCE.
UNI'll.BUILDING I-INALISSI(1NI71)13)'IiUil-f)INC, PLEASE READ RFVERSI:
IINSJIFCTOR- SIDE BEFORI:
CAI,I.IN(; FOR FINAI. JNSPI'('TlON` 19orl;u us
"IfIll, ." I. .- - - , , , ., I 1%1 11