27839 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PERMIT NO. 27839
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
- BUILDING PROJECT IDENTIFICATION
B!UIILLGING ADDRESS: I/ (/�� J/�� / ///,�l� SANITARY NO. APPLICATION SUBMITTAL DAP
O{G sfI •I a / ora a: / H D UNRp I�I� _�+ s-OTa
O PHONE: CONTRACfO AME: IC NO:
a �p�%017 HO ODO n ev, Nrc CONTROL#_
HITECTA:NGINEER: LIC NO: ADDRESS:
ONTACf: PHONE: t
. "•A ix BUILDING?ERM T WFO,-
I
QTY.1, 'ER
' r,. BLDG ELECT PLUMB MECN
PERMIT
ISSUANCE IfLbVf ILy�I( 9 /FyJn
LICE SED CONTRACTOWSO CLARATION APPLIANCES.RESIDENTIAL
01'Z I hembyam th
ffirat l am licenced underprovisiomafCTOprtr9(commencingwith 'LOB DESCRIPTION
POC Section]OBJ)of Division 3.f the Business and Professions Code.rand my,Immune is N PANELS /-1�
d.Is full forte and effect. llP T0200 AMPS \.7
<z Liance Class Lic.p
y 6 y Dart Contrare 201-1000 AMPS sallaaaa
.FOEiTV ARCHITECPS DECLARATION OVER 1000 AMPS E/SQ.FT.
;Z�0 1 understand my plans shall be used n public records.
I SIGNS ELECTRICAL
Licensed Professional
6 OWNER-BUILDER DECLARATION SPECSALCIRCUIT/MISC.
•OaU 1 hereby affirm m doer I aexempt from the Commodities Lie Law bar the
13 a,F following anon. MP
(Section]031.5,Business and Professions code:My city or many TE .METER OR POLE INST.
L S which requires a permit o construct,star,improve,demolish,or repair any structure
V>7 prior a its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
GO that he is licensed pursuant 0 the provisions of Ne Convector's License Law(Chapter
y{iL(o�' 9(commencing with Section]WO)of Division 3 of the Business end PoGarium Code) SWIMMING POOL ELECTRIC VALUATION
yxf_¢ or that he is exempt therefom and the basis far the alleged exemption.My violence of a.5 �+
FZ� Smtion7031.3bymyappiimtfm.prndesubjmmftu li=twa6vilpe lyof OITIl.E1S-SWRCHPS-FlXTURES 1
not more than five hundred dollen($500).W NEW RESIDENTIAL RUM -SQ.PT.� (jI.mownerofthepmMe ,mmyemployeeswithwage.nthelrmlecomNmanon, Q STORIES TYPECONSTURZIGOP
d willdo the work,and theewaure is not inandedorofRredfor sale(Sec.]044,Bueioess
and Professions Code:The Contractor's License Law dors not apply m m owner of
property who bu ild s or improves thereon,and wha doessuc h workNeal f or though his
ownemployeas,p Ing ori hersuch impovememmnot tea otc mplethedfm We.If,
OCC.OR .UNITS
however,the buildingurden ovemem ishaldwithin oneyeum improv for theowner- TOTAL:
builder will have irks burden of paving that he did not build a improve for purpose of
aleJ. Vit
0 1,mownerortheproWny,amexelusivelycontraetingwiNllcenndconaaerant QTY,b,7a,�_;+'A'Lnca PLUMBING PERMIT1 -?t S FEE '; FL D 0 APN
consumer the project(Sec.7044,Business and Professions Cade:)The Conoxrers PERMIT ISSUANCE
Limmc Lawdaonmapplymmownsofpropertywhobuildsorimpmvmthwec,sued
who member forsuch projects with amenacreds)limned Turnaround the Contractors
T.
License Law. ALTER-DRAIN&VENWATER(EA) _ i' SUM Y. .'I..
❑ 1 am except under S¢. B It P C for this reason BACK FLOW PROTECT.DEVICE
SANITARY Y N
weer Dem DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have a certificate ofc..t to self-inure,sea cenificeteaf FIXTURES-PER TRAP REIZEEPTa
orkers'Computation Insurance or a certified copy thereof(Sm.3800,Lab C.)which PARK FEE Y N
coven all employee.under this permit. RECEIPT a
Policy a GAS-E.A. -I INC.
.SYSTE4 OUTLETS BUILDING DIVISION FEES
Company GAS-EA.SYSTHM.OVER 4(EA) PLANCHECKFEE
❑ Candied copy is hereby furnished.
❑ Certified copy is filed with the city impaction division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Otis aced.o nd not be completed ifthe permit is forone humreddollan(5100) SEWER.SANITARY-STORM EA.201 ENERGY FEE
orales'.)
I candy that in the poformoncoofthe work for which this Pamir it issued,Imnd WATER HEATER W/VENT/ELECTR
not employ my person in any mansom sa as to Issue.subject o,the Workers' PAID
Corepevmion Lawsof California. Dm WATERSYSfEM/fRFATING pea Reaeipra
J Z Applicant
0 NOTICE TO APPLICANT.If,after melting this Comficale of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
En become subject to the Warkers Compensation provisions of the Labe Cade,you must
Yforthwith comply with such Provisions or this pemdt shall be domed revoker. BUILD E h
y (] CONSTRUCTION LENDING AGENCY SEISNXCOU70
1 hereby officer that them is a constructed leading agency forthe Performance of
Q the work far which this peanut I.Issued(Sec.309'!,Clv.C.) TOTAL: C
1<naers Name y - „ 11 /Oe� V G
Lender,Address QTY ,�� P IvIECHAMCAL PERMIT - , ia�.(FHP- fuq BIN FEE a
1 cenify that I have mad this application and ams that the above infannaaon
correct. l agree to comply with all city millenary ordinances and state laws alining to PERMIT ISSUANCE MECHA CAL FEE
r4 building construction,and hereby authorise representatives affair city recover upon the�J CON UCTION TAX a J 7 7 abovetio
-reennedry
properry far inspectionpuaae. ALTERORADDTOMECH. at
G7 (We)agree to save,indemnify and keep harmless the City of Cupertino against �y
babilities,judgmenu,costs and expenses which maty in any way atone against sold City AIR HANDLING UNIT(TO to,"CFM) A/pk,g p
in con:segmnc the Boort of this Permit.
✓. 1 j+�th AIR HANDLING UNIT(OVER 10,000 CFM)
s� �J EXHAUST HOOD Signature of Applicanr/Cantracmr Dert PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IOU."BTU) Dm Receipts
Will the applicant or fume building aacupmr mm or handle haraedoa.maarid HEATING UNIT(OVER 100,000 BT TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety U)
Cade,Section 25532(0)? VENTILATION VAN(SINGLE RESID) lverr�l, 0
13Ya C3 No
Will theapplimirmfurure Wildingurempmt useequipntentordesideswaichemir BOILER-COW IMP OR 10.000 BTU) I C�TTE
1
mrdous air contaminants as defined by the Bay Area Aa Quality Muugement BOILER-COMP(OVER IM.0o0 BTU) tlVJ1
ISIrim7 27
❑YeEls No NEW RESIDENTIAL MECH. SQ.FT. APR n ,P1(j�
tee
I have d the haaardon nomen is raquiamnrs under Chapter 6.95 of the b�l r Lit-
�f OOJJ
California Health&Safety Code,Sections 25505,25533 and 25534.1 ondenund that '
if the building does not currtndy hoveomant,that it is my responsibility the tK/ (1'r
occupant of the rt 'rttnems which must be met prior to iesumce of a Cenifne of
Occupancy.
Owneroronm� Data TOTAL: ISSUED BY:
OFFIC