27066 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B IL17 BNf;-MECHRICAI. PERMIT NO. O
APPLICATION/PERMIT PLUMBINJECIECHANIFICA
BUILDING DIVISION IJUJLDINO PROJECT IIJEN'I'INIC,ETION
BUILD 66
0AADppE SANITARY NO. APPLICYDONSUBMITTALDATE
/—J` NIT N LOT# .2vqIs
OW 1?RS NAME: PITON CONZA UW NAME; I,IC NO:
•1,,(J2f��G /A1lS z we corrrRol.#
• ARCIIIIECGINBE
'1'RNR: LICNO: ADDR S: �r�far/ 7
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 11 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pCz Ihcrehyaffi,m that lam licensed underpevisionofCTapter9(commencingwith JO DFSC
BOG Falltli�ce andel Divis3of Business and,Professions Code,unJ my license is in pnryEl-g
W
Li se Clus S Lic.N S'/u UP 9'O 200 AMPS 1
3l we ccnsrucmr w'`^ 201-I(MAMPS
ZF_� ARCHITECTS DECLARATION OVER IOW AMPS SQ.PT.FLOOR AREA $/SQ.FT.
CJ z 0 I understand my plans shall be used as public records.
F ret to SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
KOyF I hereby loft that I ore emmpt Foursome Contractor's License Lew for the
WX following museum.(Seriis"7031.5,Business and Professions Code:Any city or county TEMP.MHER OR POLE INST.
which rcquiresepemtiuo construct,after,improve,demolish,or repair any suucmm
N� prior to in issuance,alsorequires the applicant forsueh petmitto file a signed statement POWER DEVICES
�C)z rhot lm is licem
nsedpuuanfpns
to shevkionofthe Contractor's License Law(Chapter
e4 9(commencing with Section 7000)of Division 3 ofthe Business and Podressions Code) SWIMMING POOL ELECTRIC VALUATION
_,y o,that he isexcmpdiercl'rom and thatsmis fortheallegcdexemption.Anyvillitoonof OU9'LEfS-SWITCHES-FI%TURES
I..za Section 7031.5 by any applicant fora permitsubjects the applies.,too civil penalty.(
g not more than rive dollars(ES(q). NEW RFSIDENTIALELECIR _SQ.FT.
RPn❑ 1,asowncrof*epmpary,ormyemployeeswiNwagesnNcirsolecompmation, STORIES TYPE CONSTRUCTION
a3� will Bothe work,andthe structure isnot imendedmilffered forale(See.7044,Business
and Professions Code:The Connacmrs License Law don not apply to an owner of
propmy wh o bui lds m i mpseves thercan,and who does such work himml f or through hi a
ownemployces,provicked!Nat such improvememsera notimentei reoffered forsale.If, OCC.GROUP RES.UNITS
however.the buildingor improvement is sold within one ynrofcompletion,the owner- 'TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose of
❑ I,mownerof,hepropeny,ntnexclusivelycnnuamingwith licenmd contractual,1. QTY, PLUMBING PERMIT FEE PhOOD ZONC APN
ennsimet the project(Sec.7044,Business and Profession,Code:)The Comracem's
License Law does no,apply loan ownerofpropeny whohuilds orimproves tattered,and PERMIT ISSUANCE
whoexamaces for suchpmjects with a courtesans)licensed pursuant lithe Conractor's pL9'ER-DRAIN&VENT-WATER
License Law. ) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this mention — ,10{:
BACK FLOW PROTECT.DEVIL SANITARY Y N
Owner - new RECEIPT#
•
covers DRAINS-FLOOR,ROOF.A COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ ers'Coyaffiemthatlhweaoracandie conunnoaf(Seaum.or Lab C.)c hi of RECEIPT'#
FT%TUNES-PER TRAP
Wnrkcrn'Cnmpcnsati.nlmuance ora candied copy thereof(Sm.JAW,Lab CJ which PARK FF.E Y_N
acs all employee's under this permit. GAS-13A.SYST' -1 INCA OU RECEIPT#
Policy# BUILDING DIVISION PL'ES
Company GAS-EA.S TEM OVER 4( PLANCHECK FEE
❑ Caddied copy is hereby famished.
❑ Ccnified copy is fled with the city impaction division. GRRASR1 USTRL WASTE •RCE GRADING ME
CERTIFICATE OE EXEMPt)ON FROM WORKERS' GREASE AP Isi, SOILS FEE
COMPENSATION INSURANCE
(This section need no,be completed ifthe permit is for one hundred dollars($100) SEWER- ANITARY- A 2 ENERGY FEE
or lass.)
I cenify that in,he rfonn.a,/�he work forty hflsi l'�n�i�is sucd,l shall WATIiR ATER W/V /E.
not employ any ret anyant6>11 .as tQ�+/1y'r�yte�.M9Ct Jy/t^he Workers' PAID
O ,z C cnnlion Lalhmi vL I_1J- 7/ (] WATER SYS' REATING Date Receipts#
npuwm VVTS VL��
NOTICE.TOAPPLICANT:IL loRerpost this Certificate of Exemption,you should NEW RESIDENTIAL. MB. SQ.UT. TOTAL:
C/) become subject torn,Worker's Compensation provisions ofthe Labor Code,you must
LLLa"' > forthwith comply with such provisions or this pare itahail be deemed revoked. BUILDING FEE
Cis CONSTRUCTION LENDING AGENCY SEISMIC FEE
�:) z Ihereby affum that thea is a construction lending agency for the performance of
U O the work fey which this Penni,is issued(Esc.3097,Civ.C.) TOTAL: ELIiCIRIC PEE
,r larder's Name PLUMBING PEE
U Lender's Address QTY. ME Cl PIiItMIT PER UJ 1 cenify that I have read this application and state that file above information is
UJcunect. lagrcmncomply with oil city and county ordinances and s,me laws relating to PERMI'FISSUANCE MI?CI IANICAL FEE
yFrei ldingconstruction,and hereby uuthnriu representatives of this city to enter upon the
J Z ahrve-mentioned property far inspection purposes. AL7E•RORADDTOMECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and keep homeless the City of Cupertino against
liabilities,judgments,casts and e.K..which may in any wayaccrueagninst a id City AIR HANDLING UNIT(TO BLOW CFM)
in conte, t f the gromm, Fermi / a
AIR HANDLING UNIT(OVER 10,(gXI CFM)
Signature of ApplicanUCommmm Dm EXHAUST I IOOD(W/DUCD
PAID
HAZARtureb MATERIALSDIECLOSURG
HEATING UNIT(TO IW,000 BTU) Date Receipt#
Will the the Cuantorfmure builal Code,ng Chapter
9.or handle hHetlthand material I ELATING UNIT(OVER IW,OW BTU)
us dclincA by,he Cupcnino Municipal Cale,Chapter 9.12,and the Ilwlth and Safety
Code,Section 25532(d? VENTILATION PAN(SINGLE RPSID)
❑Yes ❑No
BOILER-COMP(3HP OR 100,000 BTU) ISSIDANCE DATE
m
Will theapplicamorfurcbuildingooeupen,temequiptreadordeviceswhich emit y� 6
hazardous sir contaminants as defined by,he Bay Area Air Quality Mufflip lfle0l iaBOILER-COMP IOVER IW,OW BTU) �fl
me,7
XW ❑Yes ❑No NEW RPSIDIiN17AL MECH. SQ.ff.
1 have reed the hamfdous materials eequiremenu under Chapter 6.95 of the 5z I IINV
C.Iiforele I health&Safety Code,Sections 25505,25533 and 25534. 1 understood that V V r G{9
it the building does not currently have a mnart. hat i,is my msxssnldlllry in notify the fs lir
cupunt of the ox.manlents which..at he at on.,t.issuance of a Certiliewc of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE