27839 (4) \�APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIDICDiNF; - FERMI]No.
APPLICATION/PERMIT PLUMBING.MECHANICAL 27839 O a� (]
BUILDING DIVISION BUILDING PROJECTIDUMFIFICATION G o J J
BUILDING ADDRESS: (� y/+ (/J� SANITARY NO, APPLkGT10NSUBMr TALDAII?
\ avva V/'t 2P OJ /TIG UNIT# L [LI1 —L- LOT" /����
r O QRS ME: PHONE: CONTRACfO ' AME: IC NO: NIC i COM 0.01.#
�i� awr 9PT- ODO nal+
%RCIUTEM12`1GINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
`` BLDG ELECT PLUMB MUCH
t.�5 a �� q X006' PERMIT ISSUANCE Nd Mf s01 1vS
LICA SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL Id 111 i�J ILJ
QWWz Ihembyaffrmihnllam licensed under sof Cheter9(commencin JOB DESCRIPTION
prnviaifn p gwith
F-00[ Section force add of Division J of the Business and Professions Cadc,and my license is in PANELS /-•N�
<Z, full neClass fxi. UPT0200AMP5 S
oi Zµl License Class Lit,N
m1—Z)to Dam Contractor 201-1000 AMPS
'Z8yKARCHITECTSDECLARATION OVER I"AMPS /7 A $'SQ.FT.
O Z—0 I understand my plans quell he used as public records. L
SIGNS EIPCTRICAL
L¢enxd Professr.wl
Q OWNER-BUILDER DECLARATION SPECIALCIRCUMIMISC.
SdOyU I hereby affirm thm I an exempt from Ne Comate.!.License taw for the
Is11.140 ti following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1.140 following
which requires a permit to construct,alter,improve,demolish,m repair any structure
sws'}� priarm its isxusncv,also requires Neit'Heant forsuch permit.Me.signedneremem POWER DEVICES
K C O that he is licensed pursuant to the previsions of the Comrectors License law(Chapter
4 ,a 9(commencing with Section 7")of Division 3 of the Business and Professions Cade SWIMMMG POOL ELECTRIC
y ) �/O AS-47,H1—m or that he is easmpt therefrom end the basis for the alleged exemption.Amyviolamn of GITRET$-SWITCHES-FIXTURES S—�ry
~3G Section 703 1.5I any ap d ibilltfor a s,($5Wmit subjects the applicant..civil penalt of
C no? than Bvehundreddollars yemp. NEW RESIDENTIALELECHt _SQ.FT. ,
KW m ❑ othavak,andtesureclum is ycmpladedorthwageaasthei(Sec.com7Jad.Businesson, $TDRllis TYPE CONSTRUCTION
d will do thewmk,andlheaWc.relsnot im License
Law dosed at apply 1.on Business
and Professions Cndc.'fhe Cnmmmor's License Law dcea not apply to an owner of
own prop ertywhobuildsorimpml ssthimp endwhodoessuch wokhimselfmfoougbhis
howemPloyecs,providWthrsve impis sold msercne imrofecorolfercd far ovvneL OCC GR RFS,UNITS
however,the building u improvement is sold within one year or improve for
the owner-
bds.). will have the burden of proving that he did not build.improve for puryou of TOTAL:
ale.).
❑ Las ownaofthe propcny,amexdusively, contracting with licensed contractors o QTY. PLUMBING PERMIT PF.E ISL D O APN
cmmruct the project(Sec.7044,Business and Paofesaimu Cede:)The Contractors
Licemelaw doesnot applytoennwncrofproperty,who builds or improves thereon,snd PERMIT ISSUANCE
whocontracts far such projects with aconowtorp)licensed pursuant.the Conlmctor'a pLTF.R-DRAIN&VP.NT-
L tti.Law. WATER(PA) SUM Y
Q 1 sm exempt under Sec. ,B&P C far this racoon BACK FLOW PROTECT.DEVICE O SIDE• E
f SANITARY Y N
Owner Data DRAINS-FLOOR,RCIOF.ARFA,COND. RECEIPfX
WORKMAN CDMPENSATIONDLA
ECRATION SCHOOLTA% YN
_❑ Thereby affirm that lhave aceniricute ofconsemmself-insure,on certificate of FI%TURES-PER TRAP RHCEIVf#
Wmkai Cumpensationlmunnce oreceni0ed copy thertaf(Sec.3800,Lab C.)which PARK FEE Y_N
/ ravers all employeea underthis permit GAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT#
t Policy# BUILDING DIVISION FEES
Company GAS-(LA.SYSTEM OVER 4IFA) PIANCHECK FEE /+
❑ Cenlfied copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREASEA1v DUSTRL WASTE INTERCEPTOR GRADING FEE
C[RTIPICOMPENSATION EXEMPTION PR N WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thiasatiod nadnot be completed ifthe permit is fora..hundred doRms($100) SEWER-SANITARY-STORM EA.2MM. ENERGY FEE
orless.)
I certify that in the pefamence of the work for which this permit is issued.l shell WATER HEATER WNHNT/ELECTR
net employ any person in any msrmer so as.become subject.Ne Workers' PAID
x, Compcnmtion Laws of Celifomia. Dem WATER SYSI'EM/TREATING Dmte Receim#
O Applicant
NOTICE TO APPLICANT:If,after mekingthis CatiOwm of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT, TOTAL:
Z become subject m the Workers Compensation provisions of the Labor Code,you must
�. ; forthwith comply with such provisions or this permit shall be da +med revoked. BUILD E
w z CONSTRUCTION LENDING AGENCY SETS C e 7O
5 Ihemhy affirm that is a concoction lending agency fm the performance of TOTAL: E ICF / ^0
U O the work for which this permit is issued(Sec.3091,Co.C.) 3a {7
lenders Name BIN PER / ,O�
U lenders Address QTY. MECHANICAL PERMIT IEE
I certify that I have rend Nis application and same Net the above information is
0. correct.l agree m comply with all city and county ordinances and stem laws relating to PERMIT ISSUANCE MECHA CAL FEE 3 h
UrA building smomedon,and hereby subarea rtpresentutivea of this city to enter upon the CONST UCf10N TAX a�s"�9s
above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save.indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costsand expenses which may in any wayaceme against said City AIR HANDLING UNIT(TO MOM CFM) AOX -47l
in conuquencpRf the gnntiJlg fthis permit.
(' __ /✓ AIR HANDLING UNIT(OVER IO,gMI CFM)
Signor.of of ApphcanVContmc.r/n �� / -CJI DData uAHAUSTHOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE H( TING UNIT(TO 10O,"BTU) Date Receipt#
Will the applicant or future building occupant store or handle hessrdaus material HEATING UNIT(OVER 100,00(1 BTU) TOTAL:
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Heath send Safety
Cade,Section 25532(.)? VENTILATION PAN(SINGLE RF.SID) Q 3
❑Yes ❑No
Will the applicanmrN.m buildingacupanmseequipmenmrcievices whichemit BOILER-COMP(311P OR I(#I,fklp BTU) I $Il DATE
Will
hvallow air contaminants as defined by the Bay Arm Air Quality Management
Main? BOILER-COMP(OVER 100,000 BTU) OR❑Yea N
❑No EW RFSIOENML MECH.—SQ.FT. ? 7nsNy
1 have mad the hazardous materials requirements under Chapter 6.95 of the eta r /JyS
California Heal&Safety Cale.Sections 25505,25533 and 25534. 1 understand the, ser (,'Vr thl
imf'.parm ofilm iteoes nm currently hmve a tenant that it is my mxponsibility ro nmify the N
r 'rcmems which na he ren prior to iswen ee o f
Genapency.
Owner m(tMood ed agent Date TOTAL.: ISSUED BY:
OFFICE