27838 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-Kh 1 A. PERMIT NO.
APPLICATION/PERMIT PLUMDING-MECHANICAL
BUILDING27838
BUILDING DIVISION DUILUPROJECTIUEN'TIP'ICA'1'I(yN
9uIlA1NG ADDRESS: SANITARY NO. APPI'LICATION SUBMITTAL DATE
n UNIT to /Q —� OT#
O 5 MB: PRONE: CONTRA R'S NAME: ,, LIC NO: N/C ll CONTROLM
filo 0 9Ss-6Ooo ��,tie
RCf11TECUENGINECR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INTO
QTY. ELECTRIC PERMIT FEE
C Coa P—I` 91--r-6 0,6 1 PERMITISSUANCE BLDG ELECT PLUMB MLCjI
LICEN ED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Irtd-ly IO�BI(OFSCRIPIrL'ItdOyN rU^bJT
p;z Iherebysffireathat l am licensed underprovisions ofampter9(commencing with
wa Sediom700d)ofect, Sof the Busimcss and profueione Cade,and my license is in PANELS ���
a;t�iW Pollfmcoand laaa m. t
F{Oyl Licenu Class Lic.p UP T02m AMPS
y 6 ti Date Convenor 201-Ipm AMPS
,Z EOyX ARCHITECT'S DECLARATION OVER 100()AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O<"O l understand my plans sbull he aced es puM1lic mcordv.
g SIGNS ELECTRICAL9n I I D_ rn
6 � Licensed Pmssto
fcnel �J
1' OWNER BUILDER fo nDECLARATION SPECIAL CIRCUIT/MISC.
0.#O icotU 1 hereby affirm that 1 am exempt from the Contions Cs License Ino for the
fs1�O'5 following Professionsh,or Any
city or county TEMP.METER OR POLF.INST.
,n 2 which requires a Parodi no canes the applicant
improve,demolish,file
mptir any statement
}2 prior toat he
licensed pursuant
aqui ePr eppions for suchthe Co mator'nLieaseLad sttemem PoWER DEVICES
yaj Mp that he is licensed pursoanno Ne provisions of the Contractors License Law(Chapter
d 0� 9(emmmencing with Section 7000)of Division 3 unite Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ulMm or that Sea .heisucmpuherefmmand be permit
tonhectstha plicart m Anyviolarion of OUTLETS-SWITCHES.FIXTURES 19'y 6�3 --
Fz} Sof me 03 then bya hundred
icant dollrs ot ES00mitsubjau Ne epplicantmurivil penahy,of
K� not marc than five hundred dollars(Sem). J
Q NP.W RESIDFITTIAL ELEGIR —SQ.17.o ❑do the
wrk,adteploracimisnotmtendede otheregeamthe(Sce.campensiness Q 59'ORIES TYPE CONSTRUCTION
i3= will Aothe,wes ande: he Curacum'mm�ded mothered do for of.,I,.7r an coo
erofwA Rofcssions Cate:The Commcmr's Littnu Law dos nm apply to ran owner of
property who b di Ids or i mpmves thenen,and who r as such work hi msel f or trough h i s
own employees,providW Nm suchimprovememtsara not intendialmoffered for sale.IT. OCC GROUP RES.UNITS
h ne er,the buildingor improvement is sold within one yearofcompletion,tbemwner. TOTAL:
builder will have the burden of proving that he did not build or impmve for purpose of
sale.).
❑ 1,m ownerofthe ptopeny,amexclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE Il00DZONE APN
nmuum the project(Sec.70,14,Business and Professions Code)The Cam runor's /
License Law does not applym an ownerorpoprrty who builds or improves thereon,end PERMIT ISSUANCE
who contracts forsuch projects with v conhectse(s)licensed pursuant o de,Connnrtor'v
License Iaw. ALTER (EA) FEE SUMMARY
—MIS
❑ 1=exempt under Sec. ,B&PC for this reason BACK PLOW PRO'1'IiCT.DEVICE IDE FEES
SANITARY Y N
Owner Dat RECEIPT#
DRAINS-FLUOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihercby affirm tlwtlhavescenif¢roc of comm mself-insure,orucertificvt of RECEIPT#
Workers'Compenaetion insurance orucertified copythereof(Sec.Jgm,lab CJ which FIXTURES-PCR TRAP PARK FEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYS9'EM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Ceniffed copy is filed with the city inspection division. GREASERNDUSTRL WASTE.INTERCEPTOR GRADING AEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is lorone hundred dollars(SIm) SEWER-SANITARY-STORM CA,2011FT. ENERGY FEE
or less.)
I ccnifythm mine performance of the work for which this .I,is issued,Ishdl WAITER HEATER W/VENT/CLECfR
not employ any person in any m become
so as to subject to the Workers' PAID
Cmin,miuonlnwsof Celifomia. Data WATER SYSTEMITREATING Data Rece tN
Q z Applicant
z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
rU) become subject to the Waders Compensation provisions of the Labor Code,you must
a forthwith comply with such provisiom or this Penni,shall be deemed revoked. BUILDIN /O 8+ ��
Ave., Q CONSTRUCTION LENDING AGENCY SEISMIC E
(hereby affirm thauhem is a comtrucrion lending agency for fee performance of a� ^
V 0 the work for which this permit is issued(Sea 3097.Civ.C.) TOTAL: ELECTRIC FEP TD Q 1.1
Landers Name
0 U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING E 70 Q
1 certify that 1 hove twit this city
and county
and sit film the salve laws
relating is Il0��
6,.5'--
correct. legree to amply with all city and county ordinances and state laws relating to PERMIT ISSUANCE. MECHANICAL Ef0
moxa-menti adion,wdhercbyaection purposes.
Lives ofthir citymemerupon the CONSTRUCTION' X
U z utove(mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree m wive,indemnify and keep harmless The City of Cupenst id City
liabilities,judgments,cmuandexpcnuswNchmay in any way nccrue against aid City AIR HANDLING UNIT(TO 10,000 CFM)
I �
yuan��r///uuof the granting orm
f this .it.
VW
�e MRHANDLING
(W[DUNIT T) IB.OBO CFM) r
Signa l'Applicant/Contrecir- 7���/Date P.XHAUST HOOD(W/DUCI'7
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Reccipt#
Will the applicant or furore building occupant stare or handle hazardous material HEATING UNIT(,VCR Im,IX10 BTU) TOTAL:
sea defipe
ned by the Cupertino Municipal Cade,Chaptr 9.12,end the Health and Safety qq
Coda SectionSSJ2(a)?
0 Yu ❑No �J VENTILATION PAN(SINGLE RESID) oG 7
Will the staff net orfutumbuildingmccupantuuequipmemorduicu whichemil BOILER-COMP(311P OR Im,IKKI BTU7 IS41JAWTUlffE
anardom air mmuminann m defined by the Bay Area Air Quality Management BOILER Im,OBB BTU)
"et?
❑Yes 13TI
No NEW RESIDPNAI.MECH.—SQ.FT. APR 27 1995
I have lead the humid.mmeriuls requirements under Chapter 6.95 of the CITY OF
California
ia HealthSafety Code,Sabana25505.8533 end 255]4. 1 understand that UUNEHI. U
if five building does not currently have a tomnt,that it is my responsibility to notify the
acupom outhe are remen�ct prior to ice on of a Ce tfi<me opoor to las on of a Ce tfi<me of
Occupancy ������
Ownero fhoriud agent�Data TOTAL: 704OCTISSUED BY:
OFFICE