27975 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •- ' PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL27975
BUILDING DIVISION BUILDING PROJECT IDENT'IF'ICATION
BUTLDIN ADDRESS: a, _ SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# 1.0'T#
OW SNA w— P Ccbn` CfOR'SN LIC NO: WC CONTROL
UICHITECHENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FET. BUILDING PERMIT INFO
B� ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Rnthereby affirm that l am licensed underpmvisiousof Chnptef9(commencing with
00 Section 7")of Division 3 of the Business and Professions Code,and my license is N PANELS _w a�
a is,
t full fma lass ertect. ♦v[4��{L/
<y License Class Lic.p UP T0200 AMPS
v<ci. Dore Contractor 201.1000 AMPS
7ONI"AMP
Z ARCHITECTS DECLARATION OVER IS SQ.IT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plans shell be used v public records.
M
SIGNS ELECTRICAL
RoLicensed Prnfeesionul
a< OWNER-BUILDER DECLARATION SPECIAL CIRCUITMSC.
MN I hereby affirmNm 1 am exempt from the Contractors License law for the
following ramor.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
tar which mquircs a permit to mnstrvct,altar,improve,demolish,or repair any muctum
Y� prior m its issuance,also mqusaes lheapplicam for such permit to fileesslimed stmcmeat POWER DEVICES
ya]❑C pC the,he is licensed punuwuo the provisions of the Contrs ores License Law(Chapter
6 op, 9(commencing with Section 700(hof Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
yYj_y or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHPS-FIXTURES
F._ZQ Section 9031.5 by any applicant for a permit subjwu Ne applicant m a civil Penalty of
Sy$$O not mare than five hundred doll.(5500). NEW RFSIDFNI'IAL ELECfiT _SQ.PT.
Rpm [II,asownemfthepmpcny,ormyemptoyecs wiNwagessstheirsoecompensedov, STORIES TYPE CONSTRUCTION
[[d _ will dQthewofk,and meswcmn isnmimendedmi,ffered forsale(Sm.9044.Business
and Professions Code:The Convectors License taw does not apply to an owner of
pro)Ieny who bui Ida or i mproves daemon,and who dues such work himmlf or rbmugh Ns
ownemployms,MvidcdthatsuchimpmvementimnotintendMofferedforsale.If, OCC.GROUP RFS.UNITS
bowevw the buildingor improvement is sold within one year ofcompledon.the owner- TOTAL:
balder will have the burden of pmving that he did not build or improve for purpose of
wile.).
❑ I,asownerofthepmMny,amexclusivelyconuactingwirhlimnsedmnwciorsto QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License law does not spplymmownerofproperly whobuildscrimpmvuthereon.and PERMITISSUANCE
who contracts fm such projects with a contracums)licensed pursuant to the Contactors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C fm this meson BACK FLOW PROTECT.DEVICE SANITARY OUTSIDE D FEES N
Owner Dam RECEIPT It
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION DRAINS YN
❑ Ihemby affirmNotlhaveacenificam of consanno self-insure,oracenificam of FIXTURES-PER TRAP RECE1 #
Wtakers Compensation Insurance oracenifM copy thermf(Sm.3800,Lab C.)which PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC. OUTLETS kEy•IPI'#
Policy# BUILDING IFIVISION
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FE
EI Certified copy Is hereby famished. •
❑ Certaled copy is Bled with the city inspection division. 'GRFASEJINDUSTRL WASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'; r GREASETRAP Q SOILS FEI
COMPENSATION INSURANCE T
(This action nadnot be<ompleted ifJre permit is for onehwdred dollen(fl W ORM EA.200 II E
or less.)
I certify that in this perhownu and Ne work for which Nis permit ie issua .I shady\ •WA r R L
not employ any person in any dormer so as m become subject ro rhe Wotke PAID
z Compensmionlawsof California. Date WATERSY NG Dam Receipt#
Applicant
z 0 NOTICE TO APPLICANT If,after making this Cenifcam of Exemption,you thould D _F&_R SQ.FTT TOTAL:
rr/y become subject to the Wokers Compensation provisions of Be,labor Cade,yo rZust
? forthwith comply with such provisions or this permit shall be med deerevoked BUILDING EE
sew
a (❑ CONSTRUCTION LENDING AGENCY SEISMIC
V z I hereby sffum Nthere em
re is a nsbumion leading agency for the performance of TOTAL: F.LECIRIC
0 the work for which this permit is issued(Sec.3091,Civ.CJ
LTr Lender's Name
Isndees Address a QTY. MECHANICAL PERMIT FEE PLUMBING FE
U I certify that I have nod Nis applica im and arae Had the above information is
W
correct. I ams,to comply with all city and county onironces and state laws misting m ing PERMIT ISSUANCE MECHANICAL FFcorrect. gre
building construction,and hereby authorise repoesentativesofNiscity to enter upon Ne CONSTRUCTION TAS
V Z above-mentioned pmpcny for inspection purpuses. ALTER OR ADD TO MECH.
(We)agree 199",Inde keep hamdas e C of Cupertino against
Iiabilities,'udgm r. - n man whichmayi yw accrues amatsaid City IDLING UNIT(TO IRM CFM)
in con t g it.
IR HANDLING UNIT(OVER 10,gp CPM)
Sigr to of ppllcenVCo nr Dam AIJST HOOD(W/DUCTI
PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO 100,000 BTI1) Data R kci t#
Will the the Cuantmfmumbuial Code,Capsmmor handle hHealth and Safety HEATING UNIT(OVER 100,000 BTU) OTAL:
m defined m the Cupertino Municipal Cade,Chapter 9.12,and Ne Health and Safety
Code,godi 25532(o)'t
11Yes 13 No VENTILATION FAN(SINGLE RESID)
ISAPSEBY
❑
E
Will hcepplicantarfumm M1vildingmcupantux<quiptnenwrJeviceswhich emit BOILER-COMP(3HPOR 100,000 BTU)
• maallous air contaminants as defined by the Bay Amo AU Quality Management BOILER-COMP(OVER 100,000 BTU) CI I Y Ut UUPEH IINO
District?
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT.
I have read the hazmdous materials requirements under Chapter 6.95 of Ne
California Health&Safety Cade,Seen.25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to wily the
occupant f othe rcyuircments which must be met prior to issuance of e Certificate of
sAm
panc
Owner or loth inmd agent Data TOTAL: ISSUED BY:
OFFICE