28249 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLP.C'I RICAL PHRMI T NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 28249
BU1I.DINC.DI DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADD'R^EES''S":7 /,, SANITARY NO. APPLICAII SUB HTALDAIE
v / `-'sem 0se PQM. LOT# a
WN+RS NAM':
PHONE C 'ACTOR'S AMB: 1 G${ ' N/C II ON RO p
NI L 1��OS(Eli T1'G '(3S 7Iot7 v7G L��'l
IT7:Cf/FNGINI:ER: L7U ji4S6( A �FpS,S_rs ^ I1f1 ( ." ���� ❑
CONTACT: PHONE: - (�S Y 1. (-,�V n,W BUILDING PERMIT INFO
QTY. HLECTRICPERMIT FF17
BLDG .IiCT PLUME NIECE
PERMI'LISSUANCE ❑ ❑ ❑
LIC17NSED CON TRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB ESCRIITION
Ortiz 00 Thereby of avihat Id..amlicensed B.1in,oi pmviuinnsov is Cojr1qqde 9(commencing with
SOU 7000)
ef(cans+on3nllhe Business and Professions Cotle(,vnd mylioensa is in PANI3IS '
G'yUZ W license 'a ;gN Lic.g l J UP'10 200 AMPS
h 6 W Due Camero m JYk 201-1000 AMPS
F y'y ARCHITECTS DECLARATION 'Q.PI'.FLOOR AREA $/SQ.IT.
ZZ-MOVER 1000 AMPS
. 1 understand my plans shall he used as public records.
O
Pin k cal, SIGNS ELECTRICAL
Licensed Professional ,
y�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT'/MISC.
KOyU .I hereby affirm that I vat exempt fmm the Contractor's License Law for the
W 3 Wm following ria san.(Section 7031.5,Business and Pridooma,Code:Any city or canary, TEMP.ML'lT1R OR POLE INST.
x1 which requires a permit to construct,alter,improve,demolish,or repair any stranure
�W}2 priono its issuance.alsorequires the applicant forsuch pe.it o file a signed statement POWER DEVICES
W O LL that he is licensed maximum to the provisions of the Comractor's License Law(Chapter
Y o 1)(commencing with Seeticn 1000)of On,Llo.3 of fia Business and 11 traders Code) SWIMMING POOL ELECTRIC VALUATION
_y .,that he isexerepttberefrom andthebncisfonheallcgel exemption.Anyviolnti.nof OUTLETS-SWITCHES-FlXTURIS
F Z Q Section 7031.5 by any applicant for a permit subjectn
s the applicant a civil penalty of
y
net..,a than five hundreddol In,,($500).
F'O ❑ I,usnwnerof@eprnpeny,ormyemployeeswithwages astheirsolecompemmion, NLW RESIDCNTIAI.IiLIiCTR _SQ.FT. STORIES TYPECONSI'RUCTION
6320 will do the wark,undthestmaure isnot imended.raffered f.rsale(See.1044,Business
and Profess ns CM2:The Concourses License Law does not apply to ea owner of
property who builds or improves thereun,und who docs such workhims.lfonhmugh his OCC GROUT' RES.UNITS
inn employees,providedthin suchlmproventems me not intended comfinel fared,IL
however,the buildingor improvement is sold within one year ofcompleiun,theowner- OTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sole).
❑ 1....wnerofahepropeny,am exelusivelycnmmctiug with licensed commences to QTY' PLUMBING PERMIT IEE FLOOD ZONE APN
ons rmt the project(Sec.70sl Business and Irnfessions Coi'ILe Comructoea PERMIT ISSUANCE
License,Law docs roc apply[().at Owacrl ,,,,Iy whobuildsor impnwesthereon,and
whocomacis for uch projects with a commcter(s)licensed pursuant o the Conmteroes ALTER License Law. PCE SUMMARY
❑ I ant exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.>_6 OUTSIDE FEE
SAN]LARY Y N
Owner Data RECI?IPTg
UMINS-FLOOR I+,AREA,COND.
WORKMAN COMPENSATIONDECLharN SCI100LTAX Y N
❑ ers'CI percrrnrthlostar armiifwified onxemroach See.3em aid,C.)whicnt.afh
EIX'TII 9iR TRAP RECEIPTM
Wofkers'C.,to wntion lnsurence.r ecenifed cc py thereol See.3800.LnM1 C.7 which PARK FCI? Y N
covers ullemplo ttyu er �qy RECEIPTp
,chcyis V AS-EA.SYSIEM-1 INC.40VTLETS BUILDING DIVISION FEES
Company GAS-EA.SYSTE -OVER 4(EA) PLANCHIiCK FEE
❑ Cenifed copy is hereby fumislad.
❑ Cialfial copy is fled with the city inspection division. GREASEONDUSWASTE IN11i F: R GRADING FEE
CERTIFICATE OF IiXCMPTION MOM WORKERS' GRHASE I � SOILS I ?E
COMPENSATION INSURANCE
(I'hivstttion aced not bewmplmelif the pectic is fur one hundred doll s($IW) - ANITA EA.2W FEE
m Tess.)
I cenify chat in the performance of the work fur which chis permit is issue Ishan ATE ATFJIiNT/EUI.
nuc employ any person in any manner,so as a become subject to the W, kers' PAID
Cnmpensntionl.uweof Calilnmia. Date WATE Sy l'EM/1'RL'A'1'1 Date Receiptk
NOTICE TO APPLICANT:IL after making this Cenifiemeof Exemption.you stolid NEW RESIDLNTIA .MB. SQ.PI'.
TOTAL:
. looawith comply with
the such las Compensation fanatic
Labor you
c
�' lonhwitb comply with sucb prnvlalonn or Wle pwrntt shall be JeemeA revoked. BUILDING VEE
0. Q CONSTRUCTION LENDING AGENCY - SEISMIC FEE-
z I hereby affimnhat there is a conaruri.n lending agency for performance of
U O tiro work for which this permit I,issued(See.3091,Civ.C.) 'TOTAL: ELECTRIC FEE
U
Ixmbes Name PLUMBING FTE.
0 Lendees Address QTY. MIiCI IANICAL PERMIT FEC
U I cenify thin I have read this application I I same that the nlawe information is
coi cL l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MI?CI IANICAL PEE ._
CA building construction,and hereby motorize representatives ofthiscity came,uponthe CONSTRUCTION TA% v
L) 7-. above-metniened proper,y fur inspection purposes. ALTER OR ADD TO MECH:
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liablicies,judgmems,costsand expenses which may in my wayacerue against said City AIR I IANDLING UNIT(TO W,OW CFM)
IN of- ting or a his permit.
AIR I IANDLING UNIT(OVER Ill,fi(IB CIM)
Siginotuce of Applicarru/sCimmuct., Dace EXI MUST I]GOD(W/DUC I PAID
HAZARDOUS MA' :RIALS DISCLOSURE liliATINO IINI"f(T0100,0008'fU) Date Receipt#
Will the applicant or future buildi g meupant stere or handle haz r ous mutcHal 11fiATING UNIT(OVER I W,IXIO RTU) TOTAL:
as defined by the CupertinoMunicipt)Code,Chapter 9.12,and the I leahh and Safety
Coda,Sootlon 25532(.)' V I"N'rILA"P[ON FAN(SINGLE RESOD)
❑Yes ❑No
BOILER-COMP f3HP OR 100,000 BTU) ISSUANCEppDATE
Will the appli«mor lo,as beim d by the ba eArco Air QOhl Maccaichemll P N B D
Founds air mmnminnnts as defined by the bay Arca Air Qu.lily Management. BOILER-COMP(OVER IOP LOO BTU)
Uistnd?
131:1e p
Yes No NEW RESIDENTIAL MECH.-SQ,FT. cl �y p
1 have read the hazmdoue materials requirements under Chapter 6.95 at the I(� (p
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that CITY
P f the buil ding des not currently have a lenanq that i c is my responsibility a ready the
occupant of be requirement.,which nmst ba met mm,co issuance of v Camrica.e of
Occupancy.
Owner onmthorimd.gem. Data TOTAL: ISSUED BY:
OFFICE