27222 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-LLOTRI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BTTTLDINe.PR(3dECT IDENTIF'ICAT'ION 27222
BUILDING ADDRESS: Via-
SANITARY NO. APPUCAUON SUBMITTAT
ALDE
D337 V a- UNIT#V /&M# a LOT 01
YNE�NfM //Om PHONE: CONTRACTOR'S E: LIC NO: NIC CONTROL
a /FJ{ es S/a s-60oa �e�n _P
WICHIG7.CIENGINEER: LIC NO: ADDRESS: ❑
70WACI': PHONE: ISUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
C yea 98 s'6061 BLDG ELECT PLUMB MECH
PERMIT ISSUANCE IQ Of Ib �}
LICE SED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL laIOWBLD[3CRI DESCRIPTION
Jr
MXz IImmiryafftmthvt lam llcensedunderprovisionofChepmmm
r 9(csencing with
WOO E Section 7000)of Division 3 ofihe Business and Profession Code.and my license is in PANELS
�ZtD full funereal effect. � �
F Licensense Clac Class Lic.p UP T0200 AMPS �
vs,,y Dose Convector 201-1000AMPS
ZOyz ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA ASQ.FT.
O Z-❑ 1 undersand my plans shell be used ss public,ecoNs.
<, W SIGNS ELECTRICAL
Q J Licensed Professional
Lp,aWU OWNER-BUILDER D ECLARATION SPECIATEhIRLTE-R ORPULE.
yxxOaU I hereby affirm that 1 em exempt from the Contractors License Lew for the ��
00'3 ay following reams(Smion]o3 t.5,Business end Profession Cade:Any city or county
TEMP.METER OR PULE)NST.
f-1s Oy; which murines a permit m construct,alter,improve,demalish,or acted,any ewmurc
T prior to its issuance,also nominee the applicant for such permit to file a signed statement POWER DEVICES
W �O that he is licensed pursamtto the provisions name Contractors License Law(Chapter
da 9(commeneln with Section V000)of Division 3ofthe Bmineasand Professions Code SWIMMING POOL ELECTRIC
WM gwi ) VALUATION �I
IZ"aorthmheiteumpnherefromand NeperHtfor lhcctsthe exemptttoAny ivilPeedonof OUTLETS-SWITCHES-FEHURES /9y
Zb' Semion]0315M1y any applicant for ape,mit subjects the applicant .civil Penalty of
g C1 amort than fvehundred d.11.(§500). NEW RFSIUENTIAL ELECIR —SQ.PT.
m n❑ I,usowneroHIt ',teeny,ormycmployeeswithwaga nmeirsolecampemmian, STORIES TYPP.CONSTRUCIION
d will dotbewons ande:The Contractors
Law
not apply toa4,Business J\.
and arty Professions Cale:improves
Contrvrmr.Liana nes does not apply tom owner is
propertywbobuimsm improvesch improve who doessuchwork oroffiforthrough his
employtta,pmvidrAmat such improvements umno,imendcd proffered for.ale.If. OCO GROUP RFS.UNITS
however,the building(i,improvement is cold within omyears(completion,the owner. TOTAL: `fO/
builder will have she burden of proving that he did not build or improve for purpose of
sale.).
❑ 1,asowner ofthe property,am exclusivelyconnownng with licensed mntrucmrs to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct she project(Sec.7044,Business and Profession.Cosh:)The Conasswr's
License Lawdoesnot apply munowneroftropeny whobuildsorimprovcsthe,can,and PERMIT ISSUANCE
whocoolume l'ursuch projects with aconvoctur(s)licensed pursuanrto the Conlractina
License Law. ALTER (EA)) FEE SUMMARY
❑ I um exempt under Sec ,B&PC for this reason BACK FLOW PROTECT.DEVICE O .IDE .ES
SANITARY Y N
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF, COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ertbyvem Orthat lhave ecertificate incinerator tete((-insum,aracardinals af FlXTURES PER TRAP PARK
Wmkmn'Cpmen
psmina lnrporaurtifM cnpy,M1ercpf(Sec,3800,Lab C.)whieh PARK TEE Y N
employee's all empiny 's undcnhis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 HA) PLANCHPK FEE D
❑ CmiBeJ copy is hereby horrified.
❑ CeniBeJ copy is flet with the city inspection Jivisinn. GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(T Tis section need not becompleted ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
lee..)
I renify the,in the performance of me work for whichthis permit is issued,l shell WATER HEATER W/VENT/F.LECTR
not employ any person in any m o as m become subject so the Worked PAID
Compmr,amnlswsaf Celifomia. Dates WATER SYSTEMTRFATING Date Receipt
O z Applicant
NOTICE TO APPLICANT:If,after makin this Certificate of Exemption, TOTAL:
gYou should NIiW RESIDENTIAL PLMB. SQ.FT.
z V become subjecno she Workers Comecnmtion provision of the Labor Code,you must /,
5 forthwith comply with such vision.or this OQ 6 --
P Y w pm permit shall be deemed revoked. BUILDING IEE
_ I
a []
CONSTRUCTION LENDING AGENCY SEISMIC FEE 141, IS-0
z I hereby officer that them is a construction lending agency lb,the Performance of TOTAL: PLECTRIC PEE
C1 O the work for which.this permit is issued(Sm.3097,Civ.C.) 7a 1 7QI os—
t..s Lenders Name
[v. Lender.Address qrY. MECIIANICAL PERMIT FEE. PLUMBING FEE / 70, QS_
1 renify,het 1 have mud this application aM sate shat the above information is� MECHANICAL FEE comect.Iagrcc mcomply with all city andcuunty nNinnnws unA state lawsrelminglm PERMIT ISSUANCE 70F QJ
y buildingcuntruction,and hembyaumoriu mpoesemshivesoferis city m ruttiness,the
inwoumentinned rt for inspection CONSTRUCTION TAX S y
pmpe y pec ion purposes. ALTER OR ADD TO MECH.
F7 (We)agree to save,indemnify and kap N,ml,Ve she City of Cuperto agviran —�
Iabilinc)/.,judgments,costs and expenses which may in my any accrueagaiinnsl said City AIR HANDLING UNIT(TO 10,000 CFM) /Iu
in con. ry ceofthr�g Amis permit. I��
// AIR HANDLING UNIT(OVER 10,000 CFM)
Signalman of Ap,li,aa/
Unbosom,Applicant/ Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,001)BTU) Dam Raeip,#
Will she the Ce ri or forum building e,Ch at store o,andhandlethe
hazardous material
as defnrd by the Cupeninn Municipal CtMe,Chapter 9.12,and the Hevhh and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 25532(e)?
1:1 Yes ❑Na VENTILATION PAN(SINGLE RESTD) Ll
WRIthri licuntorfatu ,building Deco BOIIFR.COMP(3HPOR 10BODOBTU) ISSUANCE DATE
pp =owl Arco Air ualily Management,
P pp
bastnct? air contaminants us defined by,he Day Arca Air Qualify Management BOILER-COMP(OVER 100,000 BTU) W D
7strim?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.ET.
I have read the hrrandaus materials regpitemma node,Chapter 6.95 sf the AN 241995
California I Icalth&Safety Code,Sections 25505,25533 unit 25534.1 understand that /�
if the building does not currently have a tenant.that i,is my responsibility m notify me C11
occupant of the requirements which must be met poor to issuance of a Certificate of U.L LUF�E
Occupancy.
Owner or awhorizeJ agate Date TOTAL:1 /70, ISSUED BY:
OFFICE