27827 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLU �IN�:R"M llR A PERMITNO. 27827� ��.pr
BUILDING DIVISION APPLICATION/PERMIT MBNO-MECHANICAL
BUILDING PROJE/CTTfIDENTIFICATION
BUILDING ADDRESS: /��r to s UNITp Ian _C-J LOTp a � SANITARY NO. AI'I'LICATION SUBMITTAL DATE
n 0
O E HS NA ?: P NF.: CONTRA TORTS NAME: LIC NO: N/C N �
Horn 9 S- Boo Own n
• ARCHITEC`UUNGINEHR: LIC NO: ADDRESS: ❑
CONTACT: PHONE
1 .e //� QTY. ELECTRIC PERMIT FEF. BUILDING PERMIT INFO
e``+ @r PERMIT ISSUANCE BLDG ELECT PLUMB MECH
K
LthatLCO ONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIALTOB DESCRIPTION
W0Z Ihertbyafnrmamlicensed under
add isifesofC Code, (commmense wird
W02 Semiorceand effect. JOf the Biomass add Profeaions Code,end my license is in PANELS ("T����
au, fullforceClass erre IT
FZu1 License Class Lie.N UP T0200 AMPS
sn Qy Date Contractor 201-1000 AMPS
z0 ARCHITECTS DECLARATION OVER TWO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O2 to to pp I andersmnd my phms shall be used as public records.
vs F u1
Licensed SIGNS ELECTRICAL a 3 s6Licensed Profexsional
E a'
OWNER-BUILDER DTION SPECIAL CIRCUIT/MISC.
OyF 1 hereby affrtn that am exempt
ConcmPt from the ContmctoYa Wcenu Lew for the
�+tr-rn which ingreawa(crofion]O]LS,construct,aineu and ve,de ioli h,de:Any<iry orcounty TEMP.METER OR POLE INST.
W f9 which requires a permit re resdueulcer,improve,demolish,file
repair any swmart
IE'<0 that hesscensed palseial to tsNevisinont for the ch Commandoes
Licame La statement POWER DEVICES
W'<0 Nat he is licensed pursuant m the provisions of the Ce Basin s Licenx law(,hepar
a':21 9t(commencing
xemit tccfmmandthe hivision Sof theed exec enon.Any ism Cocied SWIMMING POOL ELECTRIC VALUATION
o Z— orthat7031.5 by
f thepermt r the subjects thedexempti in. civil
of OUTLET'S-SWITCHES-FIXTURES a16 o(s'7•
h2Q Sectionom hadSbye undredicantfmapesmit subjects the applicant tnecivil penah of
❑ tmmmthan rofhundredny,ors(SSW).
o n❑ I,asownernf theprnpery,ormyempinyceswitM1 wages as theirsolecompenation, NF.W RESIDENTIAL ELECfR —SQ.FT. STORIES TYPECONSTRUMION
y .e will do lesions Craft:
t:no Commences License
a se Lae does not
apply to an Bus ons
and Professions Code:The Cennrecmrs Licenx law don not apply tort owner of
property who builds or improves thereon,anJ who don such work M1imaelf or through his
wnemployas.provided that such impmvememserenonimendedoroffcred foraJe.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold withinone yearofcempletioq the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for par,mrs of
sale.).
❑ I.mownerofNepmpeny.umexclusivclycmn oingwi licensedconeectorsto QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the Project(Sec.]Oa,Business and Professions Code:)'Me Contractor's PERMIT ISSUANCE'
License Lawdoes not applytoanownerefproperty who builds or improves thereon.and
who contrans for such projects with a contractors)licensed pursuant to the Commeam's
License Law. ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ I em exempt under Sec. ,H&P C I'or this rtoxn BACK FLOW PROTECT.DEVICE UT IDE F.F..
SANITA YN
Owner Data RECEIPT'#
co DRAMS-FLOOR.ROOF.AREA,COND.
WORKMAN COMPENm ofoon DCCLAHATION SCHOOL TA Y N
❑Workers
Co afrissumthat lhave
rancemlhememf ennumfmirf(Snsaram Lab
C.)c te which
IiCF.IPfN
Werken'Com PIXTURFS-PER TRAP
perosmionde,thinttraft.iedcopy Nemof(Sm.]BOO,Lab CJ which PARK FEC N
ars all employee's under this pennif GAS-EA,SYSTEM. INC.4 OUTLETS RECEIPT N
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cerified copy is filed with the city inspection division. OREASEANDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPDON FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
Ohiscection need not beccmplated ifthe pemdt is Forane hundred dollars(SIM) SEWER-SANITARY-STORM EA.200Ff. ENERGY FEE
m less.)
I certify thin in the performance of the work fin which this permit is issued,Is hall WATER I WATER WNENTIT:LECI'li `
not employ any person in any rammer an as nm become subject to she Workers' PAID
Cempaccuionlnwso(Culifomia. Data WATER SYSTEMTIZEATING Date Receipt#
0 z Applaud
Z 0 NOTICE TO APPLICANT:If,cher making this Certificate of Exemption,you should NEW RESIDENTIAL ELME. SQ.FT. TOTAL:
�+ (_q become subject to Ne Workefs Compensation provisions of the labor Cade,you must
l^ forthwith cote with such or Permit be domed revoked. BUILDING FEE
> comply wi provisions o pe
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE a/ 70
z I hereby affirm that there is a construction lending agency for the performance of
U 0 the work for which this permit is issued(Sec.309,Civ.C.) TOTAL: ELECTRIC WE
lender's Name Q PLUMBING FEE g3
O F tenders Address TY. MECHANICAL PERMIT FEE
U I cenify that 1 have read this application and state that Ne above information is MECHANICAL FEF. �� s
comet. PERMIT ISSUANCE Iegree mcomply wird Vl city aM munry ordinances mtl xtuelawa mhtingx /
Cn buildingconstruction,and herby Aathodre repreunmtivesof Nisciry in crime upon the CONSTRUCTION TAX a`
U z abm
ovcentioned property for inspection purposes. H.ALTER OR ADD TO MECst
(We)again to save,indemnify and kap harmless the City of Cupertino against
liabilities,judgments,cents and expenxswhichmay in any way amore against aid Ciry AIR HANDLING UNIT(TO 10,000 CFM)
inn quarryy''e of the griming or Npermit.is peit.
/ AIR HANDLING UNIT(OVER I0,01q CFM)
Sig mreof Applicant/Commiltor ai��� Dad 17XHAUST HOOD(W/DUM PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dete ReceiptIt
Will the applicant or future building occupant store or handle hazardous minimal HEATING UNIT(OVER IW,OOD BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,unit the Health and Safety ��}e
13 Yes 11 No
Casle;Section 25532(a)P VENTILATION FAN(SINGLE RFSID)
BOILER-COMP DHP OR 1 W,000 BTU) ISSUANCE DATE
Will the applicanmeds as building by the
muxequipmir Quality Management
t G1 p
baaNeus air connminants v defined by Ne Buy Area Air Quality Manag<mem Y' L'9 p
DiaricR
BOILER-COMP(OVER 100,0)0 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT. jl/1/(g�
I have tend the hnrardous anumials oupimmcros under Chapter 0.95 of the t�1 i're /Jtl 19gs
Calif rmia l leahb&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the V (JI-
cupum of the requirements which mus be met prior ro inuantt ofd Certinmte of �L, f ItyO
ccupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFT-IM—