27822 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N IIAI,G-ELEL'1'R[CAI, PERMIT NO.
APPLICATION/PERMIT PLUMBINI.-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION 27822
BUILDINGADOR . lli SANITARY NO. APPLICATION SUBMITTAL DATE
II''��/�/((�'VV_�l UNIT# LOTH �� /y�
pyyR;;S W�/'a Icky: CO '� 'S A`CIE:. _'It1 LIC NO: G,��
`, Y 1.5/x, `h NIC CONTROLM
• RCHITECT/ENGINC:ER: `ILIC NO:`�cqr r ADDRESS: . .— �a �/ ❑
CO AQf: PHONES: VFEE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
Sm 77k0 jB.DG ELECT PLUMB MECII
LL u� (J ((�/ PF.RMIi'ISSUANCE I�Ty�
LICENSED CONTRACTOR'S DECLAIfATION APPLIANCES-RESIDENTIAL 101 DESCRIPTION
1:1 El 11
pyL IhereM1y alarm Nminm license)unJerpnwisiomofChapmr9(rommrncingwith
x100 Seelion l0(10)of Division 3.f he Buxincse and Profcssiuns Code.and my license is in PANELS
yV F full force and eR o ` _ FPA
f<,z.m LiIsme Cla. Lic.N / UP9'02W AMPS
y=z Date HITEContract.,TDfel.( J�C'fPyA
'I / 201-IIXq AMPS t
7FOtiZ ARCHITECTS DECLARATION OVER I"AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
Oz—M Ion erstam my plans shall leased as pontic reconly.
FQ•N$,'4j Lmcnscd Profcssinnul SIGNS ELECTRICAL
NWee< OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KCW, I hereby affirm that 1 nm exempt from the Cor[tracters License Law for He
m3Omfollowing reamn.(Section]031.5.Businessand Prof¢.vinns Code:Any citynfcounty TEMP.METER OR POLE INST.
t_V 0.1 which myuires a permit in rormrua,alter,improve,demolish,or repair any structure
�'uW^]Y� primrm its issuance,aEo reylti>theapplicantplicam for such pemtiumfleasigned stammem POWER DEVICES
WC<0 Nvheislicensedpunuan[msions of the Comtactor's License Law(Chapter9(commencing with Section] ivision3e siness andProfessions Code) SWIMMING POOL ELECTRICVALUATION
m[hat he is exempuherefromsi.v for eOUTLETS-SWITCHPS-FIXTURESZ Section]031.5 by any applicae objects the applicantto a civil penalty of m mare than five hundreddu0.' 0 ❑ I,asownerofthepmpcnIre with wa es astheirsolecom NEW RESIDENTIALELECTR _SQ.ET.p y g pcnsaiimn. 5 QRTYPE CONSTRUCTION
will do the work,mWthe structintended offered forsale(SecA044,Businessand Professions Code:The C 's License Dnw does nm apply m an owner of
progeny who buildsorimprovesthereon,andwhodoessuchwork Nmselforthmugh his
employees.provide)Nmsuch improvements arcno[imm�dedarufferedtarsale.If, OCC GROUP RES.UNITS
however.the buiMingur improvement is sold within one scomformpleion,theowner- TOTAL:
builder will have the burden of proving[hut he did not build or improve for purpou of
mled.
❑ Lasnwneronhepropcny,amexclusivelycon[mctingwiNlicensedmnmcimm QTY. LUWING PER T FEE 'FLOODZONL APN
enter the project(Sm.9(144,Business and Professions Code:)The Contrac'tor's
License Law docs not apply to an owner mfpropcny who builds m [h
improvesereon,end P IT ISSUANCE
who contracts mrsuch projects with a commetrus)licensed pursuanuo[he Conuacmra ALTER IN&VENT-
LicenseLaw. WATER( ) FEESUMMARY
❑ 1 ant exempt under Sec. ,B&P C for this re ROTECT.D-VI OUT'SIUL FF.—FS
SANITARY YN
Owner Dam RECEIPT 9
WORKMAN COMPENSATION DECLARA'f10 FLOOR, F. ND. SCHOOLTAX Y N
• ❑ I hereby affirm that l have a certificate ofcomentioselSimre.ora ificateof I TURIS-P P RECEIPT#
Workers'Cnmpens:nion lnsumnce nracertiled copy thereof(Sec.38OQLab which PARK FEE Y N_
covers all employee's undathis peroun. GAS- TEM-I INC. TS RECEIPT
Policy N BUILDING DIVISION FEES
Company GAS- .SYSTE61-OV 4 EA
❑ Certified copy is hereby fumisheJ. ( ) MPAID
CK FEF,
❑ Ccnified copy i.fled with the city inspection Division. GRFASF/INDUSTRL ASTE INTERCEPTOR fila
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCIi
('Mia section need not be completed tribe pcmd[is forest,hundred dollars($InB) SEWER-S TARY-STORM EA.200FT. EF,
nr less.)
I certify[hun a performance ofthe work for which his permit is issue),l shall WATE EATER W/VENT/FLECTR
no[employ son any manner be pine[ to the Workers'z Common v a ofGBomp. Data �T3 ER SYSTEMTRGTING Date Recci tpApplicant - [ pz ONOTICE TO APPLICANT:If,after making tots Ceni cam of F.aemp[ier.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTA
� V) become mbject..me Workers Compensation provisions oflhb Labor Code,you mustforthwith comply with such Provisions nr this penrdt shall h deemed revoked.2� ,7 FIiECONSTRUCTION LENDING AGENCY EEZ) z1 hereby affirmNm N.is a construction lendingagency for the performance ofU [he work for which[his permit is issued(Sce,301 Civ.C.) TOTAL: FEE
Lender's Nunn
O V Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have read this application and state that the above infotrnetion is
Fa correct. l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
N buildingeousnuction,and hereby auNorim represematives of Nis city mentereporvhe
U z above-tnamioned propeny for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)agree tee save,indemnify and keep harmless he City of Cupertino against
l iabilinex,judgmems,cesls undexpenses which may in any wayaccrueagainet said City AIR HANDLING UNIT(TO 10,Wo CFM)
in ronscqucnce of,hc graining of this pcmii[.
AIR HANDLING UNIT(OVER IOd"CFM)
Signature of Applicam/Curnecor pact, EXHAUST HOOD(W/DUC) ,
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IIXLWII BTU) Date Receipt4
Will the applicant or future building eccupan[store or handle haverdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOg000 B'TO) T
Code,Section 25532(a)]
❑Yes CNo VENTILATION FAN(SINGLE BESIDE
Will thea licantorfo[ure Isiddin occu ant use BOILER-COME LIKE OR 100,000 BTU IS U NCE DA
PP B v egen Air orality Mange.., ) MAR S
haoardous air contaminants m Je1ncJ by the Buy Arcn Air Quality Managcntem NCOM�P 1W,IX10 BTU)
1995
Diolna'!
C Yca ❑No CII. SQ.FT. CI IT Uf V V T'cirt I IvU
I have read the haurdous mamnals requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
ifthe building not cutromly have a tenant,that it my responsibility to notify the
aaeupv mf[I rcyuircnm a whir t.)\mus me[poor[o iss n e of Cenifica[e of
caP 'y. f W S
Ow r au hunacd agent Dole
TOTAL: ISSUED BY:
OFFICE