27756(CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING• MECHANICAL I r wow 7 7 C C
BUILDING DIVISION �BOIIf(-'
DIN(;IPROJEFJIDb:N I SVICATIO(5V
N® 1
10
PERMIT ISSUANCE
El El N ❑
LICENSED CONTRACTOR'S DECLARATION
M=Z I hereby afirmthat l emlicew underprovisionsof Chapter9(commencingwith
td OO Section 70(of Division J of the Busirmveu nd Poolroom Cale. and my lice ate is in
full force aeffect. m
and
pQ,Z License,Lic.p
mQy Date Convector
Z~O vNi 2� ARCHITECTS DECLARATION
O Z _ Q l understand my plan shell be used ss public tecmde.
F t�i
APPLIANCES - RESIDENTIAL
PANEL
OO
UP TO AMPS
JOB DESCRIPTION
\ y�y-I his` r_FJ
301 000 AMPS
OR ItXp AMPS
SO. IT. FLOOR AREA
$/SQ.F
IGNS ELECTRICAL._
Licensed Professiontl
6C 6 OWNER -BUILD fr DECLARATION
ipax(, O d V I hereby vRrm thin I am exempt from the Convectors License law for the
W Oto following reuxn.(Section]031.S. Business add Profession, Code: Anycityorcnum
N 5 which h quires a permit Io construct, alter, improve, demolish, or repair any air tr
;�ii� prionoits issuance, alsorequim Ne applicant for such pemmiuo fil... igned mrnt
p that he is licensed par t m the provisions ofthe Convector's License (Chapter
dS�4o� 9(commencing with Section 7010d) of Division J ofthe Business end P rasions Code)
SPECIAL CIRCUIT'
TEMP. R INS ,
POWER
SWIM 1 1. EV4C
VALUATION
Wim mdau he is exempt therefrom and the basis for the alleged axemptio "Un
�ZaSection 703t.5 by any applicant for apermit suhjeas ban ppticanu oeivilpenaltyof
��not mart than five hundred dollars ($500).
❑ pmperty.orm compenas as
'
L. -SWIT - XTURES
W RESI A ELECIR 5 . FT.
Q
STORIES
PF.CONSTRUC
andintndedreohwegecasthcirao
willdo Nr work,und the structure is notimended reoffered forvle(Sm. ,Business
eme..,k,.dt
and Professions Cade: The Cmilo cxr's License Law does not apply to owner of
pmpenywhobuildsorimproves Nermn,andwhodcessuchwmrk himselfm t ughhix
owneeto as,pmvi provemensuene LmrndrAmabfered for e. IL
p y ded thmsuchim t t
OCC. GROUP
R UNITS
TOTAL:
however, Neavete burden ofpmentishat he withinonebuild or improve tion,Neo r-
builder will have the burden of proving that he did net build or improve far purpose o
Q� PLUMBING ERMIT FEE
ts�
role')'
Cl I,asownerofthepmpeny,emexclusivelyconvxtingwiNlicensedcontmctanto
FLOODZONE
APN
construct the project (Sec. ]Oita, Business and Professions Code:) The Contreaors
License Lawdoes not apply to an ownerofMn nywhobuildsorimpravestherton,end
p IT ISSUANCE
whocontmetaf n such projects with a commeterod licensed pursuam to the Canvactor's
License Law,
AI TER- ENT- WATER (E.A)FEI'
YtQ
❑ 1 em exempt under See. , B A, P C for this tritium
BACK FLOW PROTECT. DEVICE
TIT S
SANITARY Y N
RECEIPTM
Owner Date
DRAINS - FLOOR, ROOF. AREA, CON I.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
ofoo
❑ ers'Co vfErmthat lhave ecenaOcam of conxmereof( to self -insure, Lab C.) hickte of
Workers Compiyee'r nlir,his arra cenifiedcopy thereof(See. Lab CJ which
coven all employer's undenhie permit.
Policy M
RECEIPTM
FIXTURES PER TRAP
PARK FEE RECEIPT# N
GAS - EA. SYSTEMA INC.40DfLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVER 4 (PA)
PLANCHECK FEE
❑ Certifiede.,fsheinbyfumishad.
GREASFJINDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ CeniFied copy is filed with the city inspection Division.
CFATIFICAI'E OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS FEE
COMP PSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(This section need not he completed if Ne Permit is butane hundred dollars($100)
or less.)
WATflTER WNF.NT/ELECTR
I coolly Nn in Ne performance of Ne work (a, which this Permit is issued, label]
not employ any Front, in any mariner so as to become subject to the Workers
PAID
Z Compensation Lawsof California. Date
Applicant
ATERSY EM/TREATING
Data Rtteip,#
Z 0 NOTICETO APPLICANT:ILaRer making this Cenificnteof Exemption, you should
MWIFESIDENTIAL PLMB. SQ. FT.
TOTAL:
Vt become subject o the Workers Compensation provisions of the Labor Code, you most
a' fnnhwith comply with such provisianx .,,his permit shall be deemed invoked.
BUILDING FEE
Ila QSEISMIC
CONSTRUCTION LENDING AGENCY
O I heinby, affirm that there is a construction lending agency for the performance of
the work for which this permit is issued gra. 3097, Civ. C.)
Lenders Name
Q F Lenders Address
co m 1 cenify that 1 have rend this application and state that the above information is
correct. I agree comply with all city and county ordinances cad state laws relating m
P.
y building consumed., and herebyauNarfre represedmisesifNis city to enter upon the
V Z above-mentioned pmpeny for inspection purposes.
FEE
ELECTRIC FEF.
MECHANICAL PERMIT FEE
on
PLUMBING FEEW
PERMIT ISSUANCE
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree to save, indemnify and qp humless the City of Cupertino against
s
liahilitie ijunt ostsandexpeveswIllchmoymanyo, cane againtxid City
AIR HANDLING UNIT (T010,000 CFM)
in cn mince a of thi�}mjt_.!/^y
AIR HANDLING UNIT (OVER 10,000 CFM)
(///
Sigionme m ApplicanUC mracmrV//Dam
EXHAUST BODO(W/DUCO
PAID
HEATING UNIT (TO It30,1N10 Bill)
a ��I
HAZARDOUS MATERIALS DISCLOSU�
Data Receipt #
HEATING UNIT (OVER IW,WO BTU)
TOTAL:
Wit l the applicant or future, building occupant arae or handle hacardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health uW Safety
VENTILATION FAN (SINGLE RESID)
Calc, Section 35532(e)?
11 Yea E) No
Will Iheepplicmwrfumtrhuildingoccupanx mdeviceswhichemil
t uequipmem
• hazardous nor conmminents az defined by the Bay Area Air Quality Management
District?
ct]
BOILER - COMP (3HP OR Ifid,000 BTU)
NCEDATE
Sit ,�'
n/e� I
FEB 23
BOILER - COMP (OVER 100:000 BTU)
11 Yes 13 No
NEW RESIDENTIAL MECH. SQ. FT.
1995
I have read the hazardous materials requirements under Chapter 6.95 of theCITY
ser
California Health @ Safety Code, Sections 25505, 25533 and 25534. 1 undersmnd that
if the building docs not currently have a attend, Net it is my responsibility to notify the
cur Ctl1 INU
occupant of the requirements which must be met prior to issuance of a Certificate of
s�/f/� /�r�\
Occupancy.
1100 V" V s
ISSUED BY:
Owner or authorized agent Date
TOTAL: