27118 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO N ILDING-LLE 'I RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB LNG-MECHANICAL f] el O
BUILDING PROJECT IDEN'I'IFICA-1'ION G 1 0
BUILDING ADDRESS: G UNIT LOT S SANITARY NO. APPLICATION SUBMITTAL DA'lli VC�C /D
OWNER �TT PHON 4 NTRA ORIS NAMh;: LIC NO: 6
VMA
N/C (INTI J. q
\RCI 11'1'ECT .NGINEER: .IC NO: j4DDRLSS ❑
TO
CONTACT: PHONE:
QTY. ELECTRIC PERMITFEE BUILDING PERMIT INFO
OBLDG ll PLUMB MEC
PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Mal I hereby affirm that l em licensed underprovision marpter9(commencing with JOB DFSCRIPI'ION
u100 Scrum70011)of Division 3 of the Business and Professions Code,and my license is in PANELS
,Zw, full liarco wd ejfe� ��� � �� ��
<< VV full burr Clusse(L(S_M AZ Lick IIPT'020fIAMPS
N<°- c Commetor 201-1000 AMPS SQ. ` DOR ARIA $/SQ.Ff.
2~=— ARCIII'FECTS DECLARATION OVER 100m AMPS
Q I understand my plans she be usedis public rernNs. _
F ce(=t+1 SIGNS ELECIRICAL
Licensed Professional
�tYQ OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO W U 1 hereby elfimt but 1 am eaanpt from the Conuecmea License Low for the
al}+1'-m following teason.(Serum 703 IS,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
-� which requires a permit m construct,alter,improve,demolish,or repair any structure
}� to its issuance,.1a.m thea Ilam forsuch uo flea signedalummem POWER DEVICES
pdnr quires pp pemti
C p0 that he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter
QP1 9(namm,rain,with Section Well Division 3effic Bramessand Professions Code) SWIMMING POOL ELECTRIC VALUATION
oo or that he is exempt herefrom and the basis for the alleged exemption.Any violation of
zQ Section 7031.5 by any applicant for u permit subjects the applicant to ncivil penalty of UTIJA S-SWITCHES-FUTURES
^�
net marc than five hundred dollars MET.
t ❑ I.mownerofNeprnpeny,ormyemployecswithwagesastheirsolecompensation, NEWRESIDIiMDALELECTR _SQ.FT. STORIES '1'YPECONSTRUCTION
y3� will do the work,and the structure is not intendcAoroffered for vile(See J044.Business
and Professions Code:The Contractors Littre taw does nm apply to an owner of
property whobuildsr,orroves thereon,and whodoeesuchwork diameter thraughhis
on employees,provided that such improvements anot intended or offered for sale.If, OCC.GROUP RES.UNITS
hort wever,the buildingor improvement is sold within one year ofeampletion,theowner- AI
builder will have the burden of proving that he did not build or improve for purpose of
E]
❑ I,neawnerof the prapeny,umaxclu.vivelycontraningwith liecnved ronvncmrem QTY."- ' PLUMBING PERMIT "ITE FLOOD ZONE APN
.nsuuct the project(Sea 7044,Business end Professions Cmfil he Contractor's PERMIT ISSUANCE
License Law does not apply loan ownerofpropeny who builds or improves thereon,and
license
i e Law. ALTER
orsuch projects with ecnmmnnr(s)Iicrnsed pununnnothe Comracmor'e ALTER-DRAIN&VENIRA) FEESUMMARY
❑ ] ntexemptunderSec. B&PCforthismasn
BACK FLOW PRO .DEVICE SANITARY Y L—N
—
Owner Date RECCIPI'g
CON AREA,
IT. , .
_ WORKMAN COMPENSATION DECLARATION DRAINS- ROOF, sC1100L'fAX YN
❑ Thereby affirm that lhave accrtifiate of consentm self-insum,ora cenifiate ofRECEIPTp
'Workem'Campensution Insurance or a certified copy thercof(Sec.38011,Lab C.)which FI%TUR' -PER TRAP PARK FEE Y_N
ecsall employee's under this stood. G A.SYS R11on"
PnlcyN ! . q
BUILDING OPINION FEES
Company GAS-43A OVER 41 PLANCI IECK FEE
❑ Certified copy is hereby famished.
❑ CertifiW copy is fled with the city inspection division. GRFAS STRL TIZ F 1!PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR 'TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed Him,permit is for onehm an dollam($100) ER- BY ORM EA.200IT, 1!NERGY FEE
or leea.)
I citify that in the performance ofthe weak for which this permit is issued.)shall All It W/VENT/ELECI'R
not employ,any person in any tmmner so as to become subject to the Workers I PAID
Contpcnsation Laws of California. Date '1'nR TEM/IRPATING Dote
O z. Applicant
z 0 NO'TICETOAPPLICANT:lr..ftennnkingthis Cenifrcamof Exemption,youshould NBWRHSIDF.NTIALPLMB. SQ.FT. TOTAL:
� .V)-t Iwmmc mbjecnnthe Workers Compcnsmion provisions of the Lehm C<We,you must
� , forthwith comply with such provisions or this permit shall be deemed invoked. BUILDING FEE ^�
R. (] CONSTRUCTION LENDING AGENCY SHISMIC EEE
UI hereby affirm that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE Q the work for which mn,permit is issued(Sec.3097,Civ.C.) _—e
0
Lenders Name
PLUMBING FEE U Lenders Address QTY. MECIIANICALPERMIT FEE
I candy that 1 have rend this application and stoic that the above information is
t7^ A, correct, l agree m comply with all city and county ordinances and state haws relating to PERMI'1'ISSUANCE MECHANICALFEE r.
builAing amsvudion,unJ hereby uuthnrimmanerum...vesofthis city to enterairm the
22
f,) z rMwe-mmutioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupenimo.,.last
liabilities,judgmerm,en a dexpenses which me in anyway accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
into uence ofthe gmmingofthis earn
'a AIR HANDLING UNIT(OVER 10,000 CFM)
Z
a.tmcmf rmbJCmnmntor Out, EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HF.AT'ING UNIT(TO 100,000 BTU) Date meant k
Will the applicant or future building occupant store or handle intruders material IIEAT'ING LINTY(OVER 100,000 B1 IT
T
,is defined by the Cupertino Municipal Cale,Chapter 9.12,and the I Icahn and Safety
Code,Section 25532(.)9
11Yes 11 No V17N'I ILA'1'ION FAN(SINGLE RESID)
❑
Will the BOILER-COMP(3HP OR 100,000 BTU) . ISSUANC•DAT(:
eratcarit arms
.bottom,aby the ay equipment unlit Management
it OCT s
mous air contaminants v defined by the Bey Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) b 1 1994
rrrict'!
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT, en
F L✓r
1 have read the hazardous materials reyuiremcas under Chapter 6.95 of the t�ll(�U
California Health&Safety Code,Sections Z5505,25533 and 25534. 1 understand that
if the funding aloes not currently have a tenant,that it is my responsibility,to notify the
oruts m of the requirements which most he met prior to Issuance of a Certificate of
ccupta".
owner or authorized age at Date l' ISSUED BY
OFFICE