27213APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BnitDmc-bLhU I R
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT WENT IF-ICATiON
PERMIT NO.
27213
BUILDINGADDRESS'.
'701/33 •iQV% UNIT 0 IoT0914A-3 3z
SANITARY NO.
AWLICATIONSUBMITTALDATE
`i■yt�Gi 1�
T MJ
O �ys NAyyE: PHON':
i`7aTien em es t? S--6OM
CON'1'RACI'OR'S NAME: LIC NO:
owner
N/C
❑
C/OiNTROLp
ARCHITECT/ENGINEM: LIC NO:
ADDRESS:
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC,
.C� Cep V', -Cr 9 ``606 /
PERMIT ISSUANCE
LICENS;D CONTRACT'OR'S DECLARATION
I hereby affirm that I not licensed under provisions o(Cha der 9 (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
Section landefDivision 3of the Business and Professions Code. and my licenu is in
full force and effect
m
PANELS
L
License Close LiaX
UP TO 200 AMPS
�� �
Date Cantracmr
201 - IOW AMPS
ARCHITECTS DECLARATION
1 understand on, plana shall he used av public retorts.
OVER IM AMPS
SQ. FT. FLOOR AREA
S/SQ.IT.
SIGNS ELECTRICAL
Licensed Prafeasional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the d Contractor's Co e: Any law for the
following reawn.(genion and Professions Code: Any city orcountyractum
1
TEMP. METER OR POLE INST,
combo", shut,
which requires a pemtit to conatrun, nlmr, improve, demolish, or repair any amarum
��
pemtiuo Bleasi suwmem
issuance, also requites thetsishomt (oa,
POWER DEVICES
thanbels Co
that he is ncinaed pursuwuo the povi wins of the Contractor's License Law (Chapter
Los
9(mmmeis (commencing Sedion11100)of Division 3oRhe Bustross Professions Code)
SWIMMING POOL PIECIItIC
VALUATION
ortha h7031.5 by therefromand the haspermit subjecllegedexemptian. civilplation of
Section applicant for. subjectsthe epplicontmecivil pevhy of
-5-47,
42
OUTLETS - SWITCHES - FIXTURES
$pemtit
ht,5le hu
not marc than (vc hundred dollars ($5W).
❑ I,asowncmOhepropeny,mmyemploymwith wegnestheirsoRmmpcmadon,
`^T i
NEW RESIDHNTIAL PlECTR _SQ. FT.
STORIES
TYPE. CONSTRUCTION
willdo the work,andthestructure is not intended wofferWforsale(Sm. 1044, Business
sod Professions Code: The Counselor's License Law dura not apply to on owner of
property who builds or improves thereon, anlwhodoessuch work himselforthmughhis
own employees, providedthat suchimprovemmtamenot intendWorofferWfrraide.If,
-
OCOGROUP
RFS. UNITS
TOTAL:
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of that he did not build or improve for a of
proving P P rpose
QTY. PLUMBING PERMIT IT
❑ I,uownerof the propcny,am exclusively conrcnaing with licensed contracmrsm
FLOOD ZONE
APN
construct the pmjcn (Sec. 1(W4, Business and Professions Cade,) The Cmametar'e
License fawdoea not apply to an owner ofpropedy who buildsarimproves thermal. and
PERMIT ISSUANCE
who contracts for such projects with a coma-mm(s) IicensW pormentto the Contractor's a Law.
Lice
nl
ALTER DRAIN&VENT - WATER (G)
FEE SUMMARY
❑ am exempt under Sec. , B & P C for this tenon
BACK FLOW PROTECT. DEVICE
S
TID LS
SANITARY Y—N-
RECEIPT
Owner Da¢
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N_
❑ IhembydriMLhatlhaveaccnificnaofconwmtowlf-insum,oracenficateof
WorkersCompensation lnsurmeeoraceniftedcopythereof(Sec.38W,Lab C.l which
RECEIPfp
FIXTURES - PER TRAP
PARK FEE Y —N -
covers all employee's under this permit.
Polyp
GAS - HA.SYSTEM-I INC. 40UTLEfS
RFCF.IPI'p
BUILDING DIVISION FEES
Company
❑ Crooned copy is hereby famished.
GAS - G. SYSTEM-OVER4(IIA)
PLANCI IECK FEE �—
GR kSEpNDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified ropy is Gled with the ciry inspection division.
CERTIFICATE OP EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200FT.
ENERGY FEE
(Ildssection need not be completed ifthe permit is forme hundred dollar(SIW)
orleas.)
WATER HEATER W/VENT/BLECTR
I of that in the performance ofthc work for which this Permit is issued, l shall
not employ any person in any manner w as to become subject to the Workers'
PAID
Compemaationlawsaf Califomia. Date
Applicant
WATER SYSTEMIDUEATING
Date Receipt«
NOTICE TO APPLICANT; If, aftm making this Certificate of Exemption, you should
NEW REST DENTAL PLMB. SQ. FT.
TOTAL:
become subject m the Worker's Compensation provisions of the Labor Cede, you most
forthwith comply with such provisions or this mormit shall be deemed revoked.
BUILDING FEE 11741
SEISMIC FEE 70
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for Be performance of
The work for which this permit is issued (Sm. 3091, Civ. C.)
TOTAL:
ELECTRIC FEE
lenders Name
Lendea Address
QTY. MECHANICAL PERMIT PEE
PLUMBING FEE (! 3 SFr
V
1 coolly that I have mad this application and state that the above information is
rect. I agree to comply with all city and county ordinances and same laws rotating to
PERMIT ISSUANCE
MECHANICAL FEB
building construction, and herebymilwaimerepresenwtives ofthis city menter uponthe
ove-menned Pmsp
abtio peny for inection purposes.
ALTER Oft ADD TO MECH.314
CONSIRUCf10N TAX S
(We) sdpm to save, indemnify and keep bavnleas the City of Cupertino against
Iiabilitics,judgments,costs and exproWs which may inany way memo against said City
AIR HANDLING UNIT (TO HIM CFM)
e�-
�F �—
inconyfthegruntingofthispetmit.
//nn M �I
ATR HANDLING UNIT (OVER 10,030 CFM)
EXHAUST HOOD (W/DUCT)
PAID
Signature of ApplicunVCon rector Dam
HEATING UNIT (TO I00,030 BTU)
HAZARDOUS MATERIALS DISCLOSURE.
Date Receipt«
HPATING UNIT (OVER 100.030 PTU)
TOTAL:
Willthe uEnnicam orfumre building occupant score or handle humorous material
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
VENTILATION FAN (SINGLH RFSID)
Code, Senior 25532(a)T
❑ Yes C3 No
ISSUANCE DATE
Willtheapplicmtarfmum buiWingoccupwmxequipmmmrdevicea whicM1errdt
BOILER - COMP (31UP OR IW,WO BTU)
p�
If'
pOILER - COMP (OVER Hill" BTO)
havardous me connotations ss defaced by the Bay Area Air Quality Managemem
DlstdcO
NEW RESIDE- IAL MECH.—SQ. FT.
'
❑ Yes ❑ No
/I'e J fI N Q •f
I have mad the hazardous materials requirements under Chapter 6.95 of the
FI Y
X995
California Health & Safety Cade, Seelmou 25505.25533 and 25534. 1 mderstwd that
C' )
if the building does not currently have tenant, that it is my responsibility to notify the
cupmt of the requirements which must he met prior to issuance of a Certificate of�p�\oto
1 Y
I ur U11-
I IAV
Occupancy.
_� Y
ISSUED BY:
Owner or nuthnduJ agent Dane
TOTAL:
OFFICE