27097 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOU I R L PERM]PNO"
APPLICATION/PERMIT PLO.
BLN'G-MECHANICAL 27097 L��O(�
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION J
BUILDING ADDRESS: ''''�' SANITARY NO. APPLICATION SUBMITTAL DATE
112`5_0 Za 'ZV /Ct UNIT# LOT# Q
OWNERS NAME: q PHONE: r0... CONTRACTOR'S NAME: LIC NOro :
S Q L; bV' 2 `�o w �yyYgr{ 6<63,0
NIC bM OL
ARCIII'1'ECI'/ENGINEtili: LIC NO: ADDGSS: � ^ C ` ❑
CONTACT: PHONE: T TIC
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ pl
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DISCRIPI'ION
pyZ Ihereby affiant Nal l am licensed underprovisionsol'Chnpmr 9(commencing with
{ 00, Section 000pof Division 3 of the Business and Profusions Code.and my license is in PANELS
"Ice
t<-Zly Lieense Clad=ff t- Convncmr O 201T010(p AMPS ��• p
V~jQy Dale ' vlk�n kite
Z~ONZ ARCHHECPSDECLARATION OVER 1000AMPS SQ,FT.FLOOR AREA $/SQ.1•7.
O'L_ 1 understand my plans shall be used as pub'c rtcords
r oo F les SIGNS ELECTRICAL
Q E j Licensed PmAcssimnd ��--'—I
nc,c'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOa V 1 hereby affirm that 1 am exempt from the Contractors License law for the
W 3 a ti following mason.(Section 003 IS,Business and Profession Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit m construct,alter,improve,demolish,m repair any mmemrt
prim wits I.suanm,alao reyair..lheapPllcant for such pemtiim fileasignedstmcment POWER DEVICES
than he is licensed Puts uanno the provisions of be Cnnnumbeea License Low(Chapter
dio6' 9(commencing with Section 7WE of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
tr' or that he is exempt therefrom and Ne basis for the alleged t M violation f
taxi='rn P ge pion. ylPaimno OUTLETS-SWITCHES-FIXTURES
HZQ Soca,,, m 703 1 me
veanydreddollars apamit subjects the apPlicanuoecivil penalty of Te L7\JCJ
t2p
not more than five hundred dollars($SW). NEWRESIDENPIALELECTR _SQ.FT. STORIES TYPE.CONSTRUCTION
CFS ❑do
wrk,anhemopuclumimot amended withwed forsafeirule compassaness
will do lesions Code
ate Couto m's amended Law does of apply tom Business
and Professions Code:The mangroves
tremor s License Law dors not apply m an owner of
pmpemployes,y who buildsproyialtho Nercpn,andwhodcessuchoork teadedimulfonhrtughhis OCC GROUP RES.UNIT'S
employees,pm v iJed that such i mproverrtcros ore not intended or offered fortune.If.
however,the buildingor improvement is sold within one year ofasmpledon,the owner.
TOTAL:
builder will have 0e burden of pmving that he did not build or improve for purpose of
ales).
❑ I,as ownerofthe pmpeny,ameatlusively<ommcting with licrnud convenors to QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
construct the Project(Sec.70,14.Business and Profcssinns Code:)The Contractors PERMIT ISSUANCE
License lawdoes ma n,ply to an owncrofpropery wholmild,or improves thereon.and
whocontractsfor such projects with acontmearmid licensed pursuant to the Contractor's ALTER-DRAIN&VENT-WATER(EA)
License Law. FEESUMMARY
❑ 1 am exempt under Sec. ,B&PC for this mason BACK FLOW PROTECT,DEVICE OUTSIDEFEES
SANITARY Y N
Owner DamI
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOPRECEIPT#
SCHOOL TAX YN
❑ I hereby affirm that l have a certificate ofeensenno self-insure,or a certificate of FIXTURES-PER TRAP RECEIPTp
Wmkas'Compensation Insurance or acerified copy thereof(Sce.35W,Lab C.)which PARK FEE Y N
coven all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIP #
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ CenifieJ copy is hereby furnished.
❑ Certified ropy is Bled with Ne city inspection division. GR SUINDOSTRI,WASTEIN MKCEPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEC
COMPENSATION INSURANCE
(This section need nolbe completed ifthe permit is for one hundred dollars POW) SEWER-SANITARY-ST'ORM FIA.200FT. ENERGY ME
or less")
I certify that in the performnnee of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELEMR
not employ troy person in any summer so as to become subject to the Workers' PAID
Z Compenvtionlawsof California. Dam WATI2R SYSTEMITHEATING Date Receipt# '
Applicant
O NOTICE TO APPLICANT If.alter making this Certificate mf Exemption you should NEW RESIDENT IAL PLMB. SQ.FL TOTAL:
.�. become subject no Ne Wotkds Comp oustion provision ofthe labor Code.you must
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
UJ CONSTRUCTION LENDING AGENCY A SEISMIC FEE
U z 1 hereby off that there is a construction lending agency for the performance of ELECTRIC PEE
U O the work for which Nmit is peris issued(Sec.319'7,Civ,C.)
Lender's Name
OF Lender's Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
U I eerily that I have mad this application and stem that the above information is
Wcomet.I agree to comply with all city and county ordinances and Stole laws reladng in PERMIT ISSUANCE MECHANICAL PEE
building construction,and hereby authorise representatives of Nis city menterupon the CONSTRUCTION TAX
U Z above-mentioned property for inspection Purl. s. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep formless Oc City of Cupertino against
Ilabilitics,jedgments,costs and expemseswhich may in any way accrue against said City AIR HANDLING UNIT(T010, )
�ma.
yNis permit.ue,cc of the granting of AIR HANDLING UNIT(OV 10,000 CFM)
/0-3-
rialum of Appbcam/Com nr Date ""AUST HOOD UCD
p
HAZARDOUS MATERIALS occupant
DISCL r handl
SURE
HEATING U (TO I W.OW BTIfT Dam ftaeipt p
Will the the Cape it fdmc Municipal
C de Cap erre or handle hH ea It hTla d Safe,at TOTAL:
u defined by the Cupcmino Municipal Code Chapter 9.12,and the Health and$afery H G UNI"f( VCR 1W.0
Code,Section 25532(a)?
Cl Yes O No VE CATION FA N ESLD
ISSUAN .DAT
Will thea applicant orfumrc buildin ruse tmdevices which emit BOIL R-COMP pH R ,(NNt
pp gby the Area it
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILE -COMP(OVE ,tX10 BTU)
hsUicl?
❑Yes ❑No NEW RE DENTIAL MECH. ®V
ida 4]
1 have read the homer.,mencrs rauiremems under Chapter 6.95 of the V ttJJ 1994
California Health&Safely CWe,Sections 25505,25533 and 25534. 1 understand that
if the budding Jaevnnt currently have.mnam,that it is mymiyansibility minify the CITY UI- PUr"-f' jNU
occupant of the requirements which must be met prim to issuance of a Certificate of
Occupancy.
Owner or omNamed agent Date TOTAL: ISSUED BY:
OFFICE