27977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPERMI1 NO. ^ ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL [ y
`D wzi: ':,^fA4BUILDING PROJECT IDENTIFICATION ,0:. V1'3=='+
BUILDING ADDRESS: 1�► 1�y^( SANITARI'ND. APPLICATION SUBMITTAL DATE
21!60 ■ UNIT# LOT#
)WNERS NAME: PHONE: C HACTOR'S NAME: 3547 N)C CONTROL# ?
MRV MAU-0/
RCHITECP/EN LICNO: ADDRESS,
<JJJY� ❑
0►.�1 o t (ARv6iZ DR
• CONTACT: PHONE: wuaA: Fx FI,IrM1r+Alrt"u.v Wt=(axgtr�i ct(aF '„Y}t ee, W' eE'�J'?r .i'BUII.DIIJG PERMIT INFOl'v v,"'�^ .
��{/(�/W� //�ysy��nr��t��/� �$ QTY. ��JELECIRIC PERMIT..-Cper?"Y
J V�M e ' � Oa^T .265 OSI' PERMIT ISSUANCE
»5>St+YezG.7i.s� $S �•t tit nr; F3,E MECH
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 106 DESCRIPTION
.1'Z I hereby affirm bar l ern licensed under provisions of Chapter 9(commencing with �(,'1���-••/DESC
:O" Section]0011)of Di_v�ision 3 of thetAe Buxiness and P%on�ode,p¢d mY liceme is in PANELS
�T 2O 00 AMPS V�� PfL 0
_ full force end if uv
Z•_ Lea C ss ' Lica
<i Data Commctor 201-1000 AMPS
SQ.FT.FLOOR AREA $/SQ.IT.
,rnZ ARCHITECTS DEC OVER 1000 AMPS
'N.J 1 un ersund my plans shall be used az pu is racer
j SIGNS ELECTRICAL I
Licensed l'rofessiorul
%r< OWNER-BUILDER DECLARATION SPECIAL CIRCUR/INISC. 'eyf
%c. I hereby affirm that 1 am exempt from the Contactors License Law for the
o Lr following marson.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
< which retinues a permit to commuct,alter.Improve.d ounalish.or Mail amy structure
}� prior m its issuances also ma,iscs theepplicant for such pemtit to ftleasigrodcurnment POWER DEVICES
n p that he is licensed pursuant to the provisions of Ne Convectors License Taw(Chapter SWIMMMG POOL EIECTRIC VALE ION
9(commencing with Section]00))of Division Sof Ne Business and Professions Cale) V{�
Jm or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS SWITCHES-FIXTURES
:T< Secuw 703 L5 by any applicatorper
am far a peuuubjm¢the applicanuo a civil pcvhy of
d more than rive hundred dollars SSW). NEW RESIDENTIAL fl.EC1R _SQFT
❑ Lmownerof6cpopny.ormyemployceswithwagmmtheirsolecoml mafim, . . TYP
Sl'ORIFS E '. U N
will do the work,end the swcmm is not intended ofoffered foreale(Sec.J044,Business I
and Professions Code:The Conrremr's License law docs not apply to an owner of
property whobuadmf inaroveanorPn
e ,and whodocssochwod hirnselforthrough his .GROUR UNITS
own employ.,Provided that such improvementsara not intmdedorofferedforsale.U. / .
however the building or impmvemem is sold within one year ofcompleuon,the owner- v
builder will have the burden of paving that he did not build or improve for purpose of
sale.). FLOOD
❑ I.azowarcrmf the prmperty.em xclus vclYcmnvecting withlicemW convacmrsr ,' P�UMBPI.Gs.Clc�.aut�L'ta -s ca?. y"pF� a "GONE AP
merman the pmice,(Sce.7014.Business and Porfessionx Cade:)The Conracwrh
License Uwdoesnmtapplymanmwnerofpfop nywhobuildsorlmprovesthcmn d PERMIT ISSUANCE
whoconuscts forsuch projects with aconracmifs)licensed ptusuant m Ne Comraamr's
13crose Law. ALTER-DRAIN&VENT-WATER(EA) >F'n . or”- E E SUM ,Y?1�1'^,�, ''yt,'a{S
❑ 1 am cxcmpt under Sec. ,B&P C fenNis reason OUTSIUIi FEES
BACK FLOW PROTECT.DEVICE
NITARY YN
Door, Dole WORKMAN COMPENSATION DECLARATION DRAINS-P1O0R,ROOF.AREA,COND. SCI OL TAX YECEIPfa
C'}b p Thereby tiff thatl haviceanifwm of consem to serif-lustier,ora cenifcate of RECT:IPfa
,$ W'ohcri Compeilsauon lmumnce oraarufiedc Pv thermffgac.3800.Ub C.)whieh FlXNRE$-PER TRAP PARK E Y_IN
RECEIPT a
covers Policy a l em -ens me-crZ:i�cmi�i.gs J�(� ]a' �C GAS-EA.SYSTEM-1 INCA OIIIl.ErS BUILDING DIVISIOt FEES
Company rA TC / -- V GAS-EA.SYSTEM-OVER 4(EA) PLANCHEC PEE
❑ Cenified copy is hereby fomished.
❑ Certified copy is filed with the city impaction division. GREA$E,rINDUSTfU_WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - SOILS FEE
COMPENSATION INSURANCE
(ThisaacIran need not becomplemd o ffic permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200Fr. ENERGY FEE
or less.)
I cenify that in the performance ofthe work for which this permit is issued.)start WATER HEATER W/VENTELECIR
net employ any person in any manner so az m the Workers' PAID
Z CompenvtioMpw (grtxa�DDteT � WATER SYSTEMl11tEAT1NG Dam Reip
0 NOTICETO APPLICANT!H,af¢r making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT.
fn became subject to the Worker's Crmpemsation provisions of the Ubor Code.you most
7 forthwith comply width such Provisions or this permit shall be deemed revokM. BUILEd F 1`a
Q CONSTRUC ION LENDING AGENCY SEISMI
• Z 1 hereby affirm that Here is a construction Icnd ng agency for the performance of ] A ELECfRI IT
O tiie work for Meh Ws ppryiy�x issuey(Sec 3037Co.C)
Ixndc N tTJJ(( 4j� any y- � K PLUMBING FEE
•f— Icnd Add s QTY �;�,? e MECHANICAL PERMITr• •`e
U I enify that 1 have read this application and sure thea the aM+vc information is Od r'"2c "5i.�e.+e..v.n zwex.Zi as5k)'t'W4 >_ _
L•..1 correct.l agree to comply with all city and county ordinances and state laws misting to PERMIT ISSUANCE �s MECIIANICAI.FEE
1 building eomrucum.and hereby authodre represenouvesof this city to enter upon the rq CONSTRUCTION T AX
Z above-mentioned pmpve,indemnify
mnify and keep ha. ALTER OR ADD TO MECH.
(We)agger ersaver indemnify end keep harms the Cityco Cupenst old
liabilities.judgmenis,costa and expenses which may in any way accrue against said Cip� AIR HANDLING UNIT p010.000 CFM)
aprpcncerfthegr a, aftti.p mit.
Q
- AIR HANDLING UNIT(OVER IO.00 CFM)
PAIomm �e EXHAUST HOOD(WMUCD }f " J 1FSigna oApp mIIACRDc U
ATEJRIALS DISCLOSURE I IEATINGUNITfTO IW.WOBTU) Date Ra ii 10
Will the applicant or future building occupant store or handle hozvdous material AL:
as defined by rhe Cupertino Municipal Cede,Chapter 9.12,and the Neahb and Safety HEATING UNp(OVER I00.060 BTU) Q.
Coda Section 25532(a)? VENTILATION FAN(SINGLE RFSIDI
•
ID Yes �No .,.
BOILERISSUl3I,l�C
Will thea � 7'E
Meant or boom buildin rusee hich emit BOILER
OR IOU,O(IOITU) 1 1
pp gmccuPtm quipmcnr ordevicezw
hassrdom air emotio alit defined by he Bay Arca Air Quality Management BOILER-COMP(OVER IM,0W BTU)
j Dlatrin?
❑Yes No NEW RESIDENTIAL MECH. SQ.PT.
1 have marl the harardmi%materials requirements under Chapter 695 of the
Control.Health&Safest Code,Sections'_5505,25533 and 25534.T understand thea
if the building does not curently have o tenant.dim it is my u,,,mibili..to notify rhe
necupam requirements w h must the met prior to issuance of a Cenificac mf
oecimnnr. Zy
rri
Ow'nerr err' ihodzcd' 1m Date TO L:I ISSUED BI':
OFFIC