27244 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY. 7 /r�1 A
CITY OF CUPERTINO BUILD
ILD; .-hL..TRI AL PERMITNO. 2 1 Z T —T
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT'IDEN'TIFICAT'ION
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMITTAL DATE
UNITN LOT#
OWN 5NAA1E: PHONE: C NTRACfO ' NAME x LsC O:
S JT e UQ e /N s / N/C CONTROLN
'7RCHIIECTIENDINEFI: LIC NO: A RISS:
NTAGT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PP.RMIT PEEDLUG EI.F.CT PLUMB � MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB OF.SCRIPION
I berehyaffimllhat l am licensedunderprovfsiars.faripler9(commencing with
eetion]MIO)nf;livision3oof lf�e Businev and Professio Cade.end my license is in PANELS denseClssLic.# ea UPT02WAMPSDam Convector 20L 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z FON3 A HITECFS DECLARATION OVER 1000 AMPS
O Z C] I understood my plana shall be used as public moods.r y� SIGNS ELECTRICAL
Q; Licensed Professional
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUFVMISC.
yXO0.0 1 hereby affirm that I run exempt from Ne Coumctars License Low for be
1+130.ti following meson.(Smakin]03 L5,Business and Professions Cede:Any city or county TEMP.METER OR POLE INST.
(;�O¢ which requires a permis la construct,cm
her,improve,demolish,or repair any structure
f NYS prior to i is issuance,also requim she applicant for such Permit to file a signed statement POWER DEVICES
C a a O that he is licensed pursuant to the provisions of the Contractors License Law(Charter
W -Am SWIMMING POOL ELECTRIC VALUATION
0. eLL room,he
Section it the Division the
the Business end Pronasions Code)
_y nr than he is exempt Nerefrom it the baeisfonM1e alleged exemption.Any violation of OUTLETS-SWITCI IES-FIXTURES
Z Q Section](131.5 by any applicant for a permit subjects the applicant o a civil penalty of
tmme than five hundred dollars($501b NEW RLSIDPNTIAI.ELECIR S .FT.
n❑ I,mownerafNe prepmy,ermyemplayreswiNwegesmtheinol<cempevatiaq Q STORIES TYPECONSTRUCTION
y3� will do Nnwork,and the structure isnot intended oroffered forsale(Sm.]M4.Business
and Pro leameas Cale:The Contractor's License Law does not apply to an owner of
progeny whobuilJsarimprovestheaeen,endwhodces inch weak himselforthroughhis
wnempleyees.pmvideddletsuchimpmvementsamnotintendedorofferedforsale.IL 0.GROUP RES.UNITS
OC
however,the building or improvement is sold veiNinoneymr.foarni tion,theowver- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of 01
9°I`')' QTY. PLUMBING PERMIT FEE D ONE APN
ElI.Mowner ofthe progeny, m
aexclusively convecting with licensedconuel
aem
rs
mtrucl the project(Sm.70ski.Business and Professions Coda.)The Counselor's
License Low deeera applym anewnaofpropeaty,whobuildsa improves Nemon,and PERMIT ISSUANCE
who contracts forsuch projects widta contractions)licensed pursuant lathe Contractor`
Li.Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I iam exempt under Sec. ,B&P C far Nix meson BACK FLOW PROTECT,DEVICE OUTSIDE
SANITARY Y—N
-
Owner Dam DRAINS-FLOOR.ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby shrom that l have a cenificam nominated to self-insure,or a cerifcate of FIXTURES-PER TRAP RECEIPI'p
Workma Compenmtion Insurance cracenified copy thaeof(Sec.3901),Lab C.)which PARK FEE Y N
1] covers all emplayee'x maim this .it. GAS-EA.SYSTEM-I INC.4 OUTLETS BUILDING DIVISION FEES
Policy#
Company GAS-CA.SYS TIvFOVER 4(RA) PLANCHECK FEE
❑ Certified may is herby famished.
❑ Certified ropy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCFPTOR GRADING TLE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundneddollars(SINd SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or IessJ
Icenify that in the prrfamanca of the work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Person in any manner at 1y ba m< Jac to the Workers PAID
CompeM Iio I.a�Alj(olnjegtic se // �Z—�T WATER SYSTEM/IREATING Date Receipt#
z Applicant /1�6 [:LL�G ''((--fes 3
ZC) NOTICETOA PLICANT:IC after mokin Nie Ceri mate of Exemption,you should NEW RRSIDENTIAL PLMB. SQ.FT. TOTAL:
er become subject m Ne Wmkcrs Com. L in
provisions of the Labor Code.you must BUILDING FEB
(aSa1 > fonhwiN rompiy with such provisions or this permi¢hell be deemed mvokcd.
[� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby uffirn that hem is s construction lending agency for the performance of
O the work fur which this permit is issued(Sec.309],Civ.C.) ELECTRIC FEE
Lenders Name u' PLUMBING FEE t' Lenders Address QTY, MECHANICAL PERMIT FEE \
O I certify Nos 1 have read this application end state that be alwve information is M hGHANICAL FEE
6.
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
buildingeoustmetien,and hereby authorize represenostoesiofthis city m enter upon the CONSTRUCTIONTAX
U Z none-memioned Impeny for inspection purposes. ALTER OR ADD TO MECH.
(We)ugme m save,millennia y and keep harmless ity of Cupertino against
IieM1ilities,judgments,costs anJenpenus which meyi y of sec ugru 'd City AIR HANDLING UNIT(TO I1,000 CFM)
o sequence of the grant n t is Permit.
AIR HANDLING UNIT(OVER I0,000 CIM)
nammof Applicon4C vecmr ow EXHAUST HOOD(W/DUCII PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT TO IOIkWO BTU) Date Receipt#
Will the applicant or future building occupant store or handle harardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Sa&ty
Cade,Section 25532(x)? VENTILATION FAN(SINGLE RESID) ' -
❑Yes ❑Na ISSUANCE DATE
Will theapplicantorfumre bulldingescupantuaeequipment ordeviceawhich emit BOILER-COMP(311P OR IOO,o00 BTU) pp�S pp
mmmous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(OVER If i"BTID P N i D
D'avicR
❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.FT. NOV n J9QA
I have read the haxodam meq
mammals ruiremrnts under Chapter&95 of the
California Heuhh&Safety Cale,Smiom 25505,25533 and 25534. 1 understand that
if the building does not currently have a Mount,thin it is my responsibility to notify the CITY
occupant of the requirements which must be mel prior m issuance of a Cerificose of Vrwry/t/Jtts^u,{�
OuuPaory.
a_ Ownermemhoriud agent Dam TOTAL: ISSUED BY:
OFFICE