27661APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO " ""
APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING UI VISION BUILDING PROJECT THEN] IFICATION
PERMITNO.
27661 � � [N
6
BUILDING ADDRESS:
WCC'^"1 1 // UNIT# LOT It
SANITARY NO.
�APPLICATIONSUBMITTALDATE
�1 _
l
O N7NAME: ^h P NE:
f[.a, f el
LIC NO:
COi jtACr R'SN ��
N/C
❑
CONTROLp
RCHITE /ENGINEER: LIC NO:
ADDRESS:
'UNTACI': PHONE
'
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT' PLUMB NIECE9VO1
IIrX�gl ❑ ❑ ❑
PERMIT ISSUANCE
LICENSEDCONTRACTOR'$DECLARATION
I herebyaffirm Nall am licensed under promimasofChaprcr9 (commencing with
Section 7") of Division 3 of the Business and Professions Code, and my license is in
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
WG✓(Y.�� � �r(O+r /
PANELS
full fore. and affcm.
LicenseC Lic.#
UP T0200 AMPS
2
�u w✓:/�„Z'.�
S�F�C�R�
201 - 1000 AMPS
Da¢ Comaacmr
ARCHITECTS DF,C ARATI N
1 understand my plans shall he used as public recoMs.
OVER 1000 AMPS
.FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licemed Professional
OWNER -BUILDER DECLARATION
SPECIALCIRCUIT/MISC.
I hereby affirm that 1 am exempt from Ne Contractor's License Law for the
following reason. (Section "1031.5, Business wd Professions Code: Any city m county
,
TEMP. METER OR POLE MST.
Permit to
which requires a pert consumer, alter, improve, demolish, or repair any structure
,no,
prior m its issum,a..I,c requires the ... li..t for such pertniuM file asignedstatement
POWER DEVICES
that he is licensed pursuant an the provisions of Ne Commodities License Law (Chapter
9 (commencing with Section 7") of Division 3 of the Business and Professions Code)
or that he is exempt herefrom and the basis for the alleged exemption. Any violation of
Section 7131.5 by any applicant for a worrit subjects the applicant to a civil penalty of
SWIMMING POOL ELECTRIC
VALUATION
(/
OUTLETS - SWITCHES - FIXTURES
t more than five hundred dollars (S500).
❑ 1,asowneroftheproeny,ormyemployceswithwagesastheirsolecompnmion,
NEWRJESIDENTIALELECTR SQ.FT.
STORIES
TYPECONSTRUCTION
will do the work, and the structure is not intended oroffead forsale(Ses.9044, Business
and Professions Code: The Cmansolnea License Law duce not apply to an owner of
property whobaildsor impnovestheaon, and whodoes such work hirmelforthroughhis
al such improvementsareaot intended proffered hostile. If,
employees, providedthat fo
OCC. GROUP
RES. UNITS
TO"TALI
bnwes. , the building or impmvemcnt is sold within one yearofcompletion, the owner -
builder will have the burden of that he did not build or improve for f
proving p varpa.,ea
QTY. PLUMBING PERMIT FEE
ailed.
❑ I, as owner Mile property. amexclusively contracting with licensed contractors to
FLOOD ZONE
APN
L,natruct the pmjee, (Seo. 9044, Business and P ofes,our, Code) The Coulowlpr't
icense tawdoesnot apply m an ownerolfavrany whobuilds or improves Nemmusnd
1.12RMIT ISSUANCE
wmenntmns forsuch projects with. emposimr(s) Eventual Pa...uo the Contmnols
License Law.
ALTER (EA) )
FEE SUMMARY
❑ I am exempt under Sec. , B & P C fpr this m.m
-
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPT#
Owner Date
DRAINS - FLOOR,ROOF, AREA,COND,
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX YN
❑ ens'Co affimtthat lhave . cenifi scare consent topyrilp self-of(Stsure,M, aid, C.) hich
lWorkverse ahem' pye�MntceoW<m`f'ied copy Ncrcof(Sx. J900, 1sb CJ which
Policy # !� J Z�n.7p 93
RECF.IVfp
FI%'TURES - PER TRAP
PARK FEB YN
��1�#
GAS -EA. SYSTEM -I INC. 4 OUTLETS
BUILDING DIVISION FEES
Co.pat,y a- T4(al, v
❑ Courier copy,., herem
by futshN.
GAS -EA. SYS A)
DE
PLANCHECK IEE
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING EEE
Counted! copy is fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS
GREASE TRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM Is. 200FT.
ENERGY PER
(This.aaion need notbe coopleud iffy, permit is hours, hundred doll. 1$100)
lass.)
WATER HEATER W/VCNT/ELCCfR
I certify that in the perfomurneafthe walk for which this permit is issued, I shall
apt employ any person in any monomer so as to become subject to the Workers'
PAID
WATERSYSTEM/fREATING
Compensation Law,MCalifomie. Data
Date Receipt#
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
NEW RESIDENTIAL FILMS. SQ. IT.
TOTAL:
become subject to the Workers Compensation provisions of the labor Cade, you must
forthwith comply with such provisions or this Permit shall Ire deemed revoked.
BUILDING HE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm me,them is n consumerism lending agency for Ne performance of
the work lin which this Permit is issued(Sce. 3099. Civ. C.)
TOTAL:
ELECTRIC IEEE
Leader'a Name
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Address
I cenify that 1 have read this application and sure that the above information is
correct, lagree to comply with all city and county ordinances sndstam laws relating to
PERMIT ISSUANCE
MECHANICAL FEE
buildingconsuuction, and hereby suthoriu representatives of this city roamer upon the
Monve-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
Wo) agree to save, indemnify and keep hi mdus the City of Cupertino against
liabilities, judgments, cost and expenses which may in any way accrue against said City
A IR HANDLING UNIT (TO 10.000 CFM)
cono,u s oft grenti polis 5F9
l
AIR HANDLING UNIT (OVER 10,000 CFM)
S,fialurepl' Applicant/ on r Date
17XHAUSI' HOOD(WNUCTI
PAID
HEATING UNIT (TO 100,(100 BTU)
HA DOUS MATERIAIS DISCLOSURE
Date Receipt#
ImATINauNIT(OVERIW,NX)I)TU)
TOTAL.
Will the applinm rfunae building occupant store orhandle hazardous material
as defncd by the Cu Wino MunicipalCMe. Chapter 9.12. and the Heahh and Safety
VENTILATION FAN (SINGLE RFSID)
Code, Section 25532(x)?
❑ Yes ❑ No
ISSUANCE DATE
Will lheapplicanlorfmurebuilding«cupantusc equipmenlur Device., wM1ichemil
Islanders air contaminants as defined by the Bay Area Air Quality Management
District!
�❑'Yes 0 N
BOILER -COME (3111) OR IW,fNNI BTU) '
/�
#+ p'
a�oI1' 4 D
'1/
BOILER 100,000 BTU)
NEW RESIDENTIAL MECH, SQ. FT.
1 have read the bvanlous nationals requirements under Chapter 6.95 of the
California Health & Safety Cola, Section, 25505, 25533 and 25534. 1 understand that
2 n
if the building dnes no, currently have a reran., that it is my resrymsibility to amity the
occupant of the requirements which must be met prior to issuance of a Certificate of
r 1'UN
Occupancy.
ISSUED BY: O
Owner or.amhorined agent Date
l'OTAL:
OI -Hut