27251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bun,ILDIS(i TF.L' APERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL C
BUILDING DIVISION IIUII.DING PROJRCI'IDRNTIFICAIION J
BUILDING ADDRESS: �// ///] '/�)n SANITARY NO. APPLICATIIONSUBMIII'AL DATE
0/ FN)9114 Y/G_.a UNITX LOT# I �— I
OW S� E:rris Sd ON go Owac NTRq(TO ME: LIC NO: 111
S NX CONTROL
RC IITECT4NGINEE LIC NO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE L9 IYI
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
GKZ I herehy uffian that l am licensed under provision.vofChapter9(commencingwilh 2
+000 Sa9on 714X1)of Division 3 ofthe Business and Professions Code,and my license is in PANELS
full form and effect.
FLynse lVj Licenss I.ic.a IIP T0200 AMPS
y Q y Dam Convector 201-HIM AMPS
F PisZ
ABOUT ECT'S DECLARATION SQ,FT.FLOOR AREA SISQ.FT.
ZOrn—
OZ—=
1 underaanJ my pl...M1all be used as public records. OVER Billy AMPS
F.rn F w SIGNS ELECTRICAL
E w ce Q Licensed Professional
a' On I con BUIL,fir.. he
/ SPECIAL CIRCUR/MISC. -OD
KOyU I hereby affirm then 1 am exempt from the Conimcto o L:Anne U.forco the
F 40 vFi following rtasan.(Section construct.
Business and Pre docaona Cade:Any city s county TEMP.METER OR POLE INST.
which rite mx u e.i—itdw 1.o comma,alter,improve,demolish,or repair any awmum
�'Yo
its licensed pursue the ions of the Co vo License
mew statement POWER DEVICES
Prior 4mres PP peani 6
0.E0 the he is licensed pursuant to the provisions of Cnmmnors License Lew(Chapter SWIMMING POOL ELECTRIC
6ip� 9(tommeneit,with Section 7").f Division 3 ofthe Business end Professions Code) VALUATION
yKj_y or thatheisexempttherefromandtheNexisforrheallegedexemption.Anyviolationof / o0a
FZY Section 903 L5 by any applicant for a permit subjecn the applicanUoeCivil perWry of OUTLETS-SWRCHES-Fl%TVRES a b
GZC nor morerhan Five
rofthe rolny,las(5500). NEW RFSIDENTIALELECIR _SQ.FT. SPORLES TYPE CONSTRUCTION
IY�p% ❑ LnsowncmFlheproperty,mrmyemployeeswith wages avheirxalecompcnsetion,
c, 22 will do the work,and the stracaure isnot intended ondfcrcd forsale(Sm.94q Business
and Professions Code:The Contmcmr's License Law does not at tom owner of
property w ho bu it ds or improves the rton,and wh r does such wmk himxl f art though hi a own
employees.provided Nat such improvemare mm
eom al ierWm
edoffeml foraale.if, OCC GROUP RFS.UNITS
howevem the building or improvement is sold within one yemofcomplerion,theowner- TOTAL: pD
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ L.asownerollhepoprty,amexclusivelyconlractingwiNlicrnseJconvacrmslo QTY. PLUMBING PERMIT FEE FLOOD ZONE AIN
construct the Project(Sec.7044,Business and Professions Code:)The Convector's
License Lawdoes nor applymanmwnmoflampery who builds or Lmprovcatheremn,and PERMIT ISSUANCE OO
whoconrracrs for such ponjects withaconvawk,ba)limned pursuant lathe Convacmts ALTER-DRAIN&VENT-WATER EA
Lim.''wen. ( > FEE SUMMARY
❑ 1 am cxempl under Sec. ,B&P C for this reason BACK FLOW P0.0TECT.DEVICE OUTSID� TEF
SANITARY YN
Owner Date RECEIPT#
• c DRAINS-FLOOR,ROOF,ARG,COND.
WORKMAN COMPENSATION DEC TION SCHOOL.TAX YN
❑ Ihemby affirm thatlhavencenificam of con nos 'Rin um,of a re of / FIXTURES-PER TRAP �Jf RECIiIPfp
Worker:Coployee, a&,tmnc armimnified cop h 5�.3800, hich b Xw PARK FEE Y N
rs all cmPltyce's undenM1ie permit. X GAS-EA.SYSTEM-1 INC.4 OUTLETS RLCLDTX
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(PA) PLANCHECK FEE
❑ Cenifedmpyisherebyfumished. /
ClCeriGcdcopyis filedwnt thecityi di'BiL GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFTCATEOFEXEM N OMWORKERS' GREASETRAP SOILS PEE
COMPENSATION 1 U NCE
(Thin section need not be cnmukted irthe pe isformehundmldollars(8100) SEWER SANITARY-STORM PA.200FT. ENERGY FEE
or less.)
I cerifythar in the yeffoanence ofthe walk for which Chia per mit is issued I,bsH WATER HEATER WNENTIMECIR
not employ any person in tiny manner so as to become subject to the Workers PAID
Compeneaiosluwaof Califomia. Data WATER SYSTEM/TREATING Dae Ranula
zZ Applicant
0 NOTICETO APPLICANT If,after making this Cenificam of Exemption.you should NEW RMI DENTIAL PLMB. SQ.Ff. TOTAL:
F" fn timmoranhjealmtheWorker',Compensation proskinas ofrhe Labor Carlo,you must
04 ; forthwith comply with such provisions mild,pe and,shall he deemTE
ed minovIL BUILDING FE �O
W CONSTRUCTION LENDING AGENCY SEISMIC FTE a60
1 hereby affirm that there is a conaruction lending agency for the performarme of
u O the work for which thisprti t is issuedat.(S 3057,Civ.C.) TOTAL: 7-oo ELECTRIC FEE ,10
Lender's Name
F lenders nddmmm QTY. MI3CIIANICAL PFiRM1T' FEE PLUMBING ME 7 a�
L) I certify that 1 have read this application and state that the above information is MECHANICAL FEE mast.I agree to comply with all city told county ordinances slid sum laws relating to PERMIT ISSUANCE
•�" N building construction,and hereby auNorim,representrtiveaofthiscity to enter upon the CONSTRUCTION TAX
V Z above-nmnrioned Pmpery for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and kip harmless the City of Cupertino against
liabiliums.judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
�consequence of the granting of this mmir.
�� ^A�Co AIR HANDLING UNIT(OVF.R 10.(100 CFM)
S.gnmu fApplicmr/Comr I Date EXHAUST HOOD(w/DUCG PAID U
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO that"BTU) - Date k Receipt,# [
WIII Om applicant or man,handing nocturnal storm lir handle hueurdous macnal HEATING UNII'IOVBR 100.000 H'1'Ul TOTAL: � 7. O
as defined by the Casimir.Municipal Code,Chapter 9.12,and the health and Safety
Cade,Section 25532(a)P VENTILATION FAN(SINGLE RISID)
13 Yes ❑No
Will rhe applicamorfumrt building acupam uxequipmentordeviaswhichemir
BOILER-COMP(3HP OR 100,0W BTU) lPISajN0 DATE
hazardous it comaminams as Jclined by the Bay Amu Air Quality Management BOILER-COMP(OVER 100,000 BTU)
DinricT! qry� 1Q/nA
11 Yes 11 No NEW RESIDINTIAL MECII. SQ.IT. PIUV Iaa�
1 have mad the ha ardour mamdals requir mems under Chapter 6.95 of the /1
California Health&Safety Cale.Sections25505,25533 and 25534. 1 understand Nat GILT Ur VUfCMIINV
if rhe building docs not currently have a mnmt,that it is my impossibility to notify he
occupant of the mquirements which must be met prior to issuance of o Certificate or
(koupancy.
Owner or amhorircd agent Dam TOTAL: ISSUED BY:
OFFICE