27015APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
1'FIL'- el. ..
CITY OF CUPERTINO PLUMBING - MF-CHANICAL
BUILDING DIVISION ,APPLICATION/PERMIT
. a, q' rBUILDING PR(3JECT,IDRNTIFICATION± m-. 'rg. $ 1:
PERMIT NO.
27015
DD17LDING ADDffRRF-SS:�/
-SANITARY NO.
APPLICATION SUBMITTAL DATE.
/ �) IJ IaJWry v(/IW �"vx- Iv UNIT LOT#
95
OWNERS NAME:PHONE:
t -d/3- i
�(,Ly
C NTRACTOR'S NAME: - LIC NO:
e iVIO / ()S-
N/C
❑
CONTROL#
CHITELT/ENGINEER: LIC NO:
ADDRE B:
CONTACT: PHONE:
on* = 6' 1,B! R %.iv R I
lib OWN TB��� 1�4 4
tg,g- ` =BUILDING
PERMFFINFO w
BLDG ELECT PL,{U,wA1B MECH
PERMIT ISSUANCE
❑ ❑ya 0
I"
LICENSED CONTRACTOR'S DECLARATION
1 herebyaff,. that l am licensed ander provisions of Chapter (commencing with
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
Section]000) of Division 3 of the Business and Professions Code, and my license is in
full force and effect.
License Class Lic. #
UP TO 200 AMPS
pep
V
201 - 1000 AMPS
Date Contractor
ARCHITECTS DECLARATION
SQ. FT. FLUOR AEA
$/SQ. UT.
OVER 1000 AMPS
I understand my plans shall be used as public records.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC:
I hereby affirm Our I and exempt from the Con[mcmrs License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
TEMP. METER OR POLE INST.
which requires a nation to construct, alma improve. demolish, or repair any more.
primm is issuance, also requires theepplicnnt farsuch permit to file. sigaedsmtemem
POWERDEVICES
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter
9(eommencing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and he basis fee he alleged exemption. Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant to a civil Penalty of
OUTLETS - SWITCFIES -FIXTURES
❑ five
not more than foe hundred dollars ($500).
ny,orm$500). yeeawith wagesestheireolecompeneetiov,
NEW RESIDENTIAL ELECTR _SQ. FT:
STORIES
TYPECONSTRUCTION
colIdothework, and thestructureis rotintendede nfw
doforsale(gee.t a4, owner
and Profusions Code: The Contractors License Law does not apply to an owner of
own ,openywhob,pmvr iedtha"schimogand who anduachwdedoroselforthrnigh sale.Is
emplthebuiprovided auntenotintendedorofferedforsale. If,
sackimpis
OCC. GROUP
RES. UNITS
TOTAL:
sold
however, thebve the mimprovementiehathe didnot year of improve for thrower-
pr
builder will have the burden of proving that he did not build or improve for purpose of
Ado.).
am ng licensedconracmfsto
❑ Iuct
i {,
las.1" $ V80'vaffiS£iw`Aa'.'i` &, 5k
Q7 i'n PLUMBI G PERMIT. FEE ,
ap, y s iQy wr
FLOOD zorvE
APN
the project (Sec. 70,1 Business C
Loans c[ the project (Sec. '1(14 A, Business and ywhosiova Code:) The Contren,and
License Lawdoesnm apply manownerofpmpenywM1obuildsorimproflit
PERMIT ISSUANCE
-
Cmucaend
whenseLoctsforsuchprolec[s with acontracmrt%)licenced pursuannotheCon[mcmr's
License Law.
ALTS -DRAIN& T WATER (EA)
f T+pFmM+a'yIg SLMtv'IA'BY
�_B.7��}}ry-§'#+y,
,;}#
❑ 1 con exempt under Sec. , B & P C for This reason
BACK fk0f)ROTkCy. DEVICE
ID
.EES
SANITARY Y N
RECHIPI' #
Owner - Da¢
D 00 AREACONT
,, .
WORKMAN COMPENSATION DECLARATION
SC1400L TAX Y N
I hereby affirm that l have a certificate ofcoaiout to self -insure, or a certificate of
orkers' Compensation Insurance or a certified copy thereof (See. 3800, Lab C.) which
cover% all employee's under this permit.Gp,
Policy #
-RECEIPT#
PI PER TR
PARK FEE YN
RECEIPTN
_ .SY T M -I INCA OUTLETS'
BUILDING DIVISION RES
Company
G4"- A. M-OVER4 HhO
PLANCHECK FEE
❑ Certified copy is hereby banished.
' S � N TRL WASTE INTERCEPTOR
GRADING FEE
❑ Certified copy is filed with Ne city inspection division.
CERTIFICATE. OF EXEMPTION FROM WORKERS
SC TRAP
SOILS FEE
COMPENSATION INSURANCE
SE ANITARY - STORM EA. 201
ENERGY FEE
(This section need notbe completed ifthe permit is force hundreddollars($10(d)
or less.)
WATER HEATER WNENT/ELECTR
I certify that in the parrormancevfihe work for which this Permit is issued, I shall
not employ any person in any meaner so as to become subject in the Workers'
PAID
WATER SYSTEIMTREATING
Compensation Laws of Califomia. Date
Date Receipt#
Applicant
NOTICE TO APPLICANT: If, after making this Cenircale of Exemption. you should
NEW RESIDENTIAL PUNTS. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat them is a concentration lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Co. C.)
ELECTRIC FEE
Lenders Name -
Lenders Address -
& Mi},q�a.&ax##"'*uoS F?+ x
„MECHANICAL�PERMITa - �-; ?a 'Ep'
k 2+.-'. ". &.•sra OBT Y 'r,
PLUMBINGFEE
I certify that I have recd this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
s x:a C•.
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby authorize representatives of this city in enterupon the
above-mentioned progeny for inspection pu ses.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) agree m save,' damvify a harmless he City of Cupertino against
-
�s
liabilities,judgm ,co .andex ch y in any way accrue against said City
AIR HANDLING UNIT (TO 10,000 CFM)
Inconhe of the Ong Thi trot[.
AIR HANDLING UNIT (OVER 10,000 CFM)
Signnure or Applicant Dace
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (T0100,0W BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cap adino Municipal Code, Chapter 9.12, and the I lealth and Safety
HEATING UNIT (OVER 1 W,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
_
Cade, Section25532(a)1
0 Yes El No
BOILER - COMP (3HP OR loroyan BTIp
ISSUANCE DATE
� '
A r
Will the applicanmrfumre bvildingoccupanmuequipmenmrdevices whichemit
hamrtims air manufactures as defined by the Bay Area Air Quality Management
istnet?
BOILER - COMP (OVER 100,000 BTU)
❑ Yes ❑ No
T have read the haoadlers materials requirements under Chapter 6.95 of the
��� :fn^`
NEW RESIDENTIAL MECH. SQ. Pf.
CaliforniaHealth & Safety Cale, Sections 25505, [list it is and 25534. I understand Net
tribe building Healtoesnmcurrentdahaveans 25505,25 i%myd responsibility ummnmify[he
a�+ss 199,V�
V11r
ec of the requirentenm which must ba met pdonv issuance of a Cmificate of
UH (r�L�\
'
Occupant
pancy.
(]'J�1�/y/L/t■may
I �:`" I �' I
ISSUED BY:
Owner cu mora deed agent Date
'DOTAL:
OFFICE