27985 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.w CITSGOF CUPERTINO •• .• A. PERMIT No. ^
I BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L
IIUILDING PROJECT IDPNI IPTCAI'ION
BUILDING ADDRESS: SANITARY NO. (APPLICATION SUBMITTAL DATE
O ON IT LOT �S
OWNS NAME PHONE: CONTRACT R' AME: L LIC NO:
q�• N/C CONTROL#
ARCH( IENGNEE : LIC NO: ADDR
E5377 g , P +lot .'N
CONTACT: PHONE:
QTY. .: '.`.ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG LE PLUMB MECH
PERMIT ISSUANCE JCI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
nwz I hereby affirthat l am licensed underprovisionsofCNpter9(cotnmencingwith JOB DESCRIPTION
WOOp Section BIN)of Division 3 of the Business and Prof®sions Code,and my liame,is in PANELS
FKUU full force and effect.
FzW License Class Lim.at UPT0200AMPS � 1
m<y Uutc Conoaztm 201-IM AMPS S FT.FLOOR AREA S1SQ.FT.
zOyZ ARCHITECTS DECLARATION OVER 1000 AMPS Q.
0z 0 1 understand my plans shall be used as public records.
y
t uJ SIGNS ELECTRICAL
mgLicensed
w<
igQwu OWNER-Bempt fr DECLARATION SPECIAL CIRCUIT/hBSC.
�SOaF I hereby affirm that 1 am exempt Trom the Containment License law for Ne
R+E: fmWwingrtasoa.ermit to R031.5ct,met.land Professions Code:Any city or county TEMP,MEfER OR POLE(NST.
W1=Liy� requires a permit to comwer.elteoitfm.udetrmlish,mrcpaig emy dtwcturc POWER DEVICES
prianoid issuance.also rtquires Ne applimmtfor such perminofileesigncd statement
y)�p0y that he is licensed pursus it to the pr..War,of the Contractor's Limense law(Clutpter
n. 0K 9(commencing with Section]000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION XW_m urthat heisexempt
,.,Iitherefrom and the ba.i.for Nen,l, eexificamn.Anyviseemnaf OUTLETS-SWITCHES-FXTURES � 'r
yQ not more
than by hundred dollars
applicantmaeivilpenalty of .�/(�
r� tmLig.wn r.fthedredda,co ray500). NEW RESIDENTIAL ELECTR -SQ.FT.
Ce n❑ I,asownerofinepropeny,ormyempin swiN mtheirsolecompetw0on. STORIES TYPE CONSTRUCTION
d3e�° will dr,dw wnrk.andthcmucture isnot mieno r for sale(See.70,Ps,Business
and Professions Code:The Commcto' i it s not apig y--heyb caner of
property .yexe.ldsa provese iii n, d so work hitt mha.Is
nemployeea . t t ch emrnrsercn so Irndedor df tough
is I OCC.GROUP RES.UNITS
howevm,thebm ing ernerises he hi 5Syy a adFfP et eownsummer. TO A
builder will hover a not provitReVcod twfbui
Prove or of
raleJIm
. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I.mownerofthep ny,ame 1 named g with licensed contractors to
construct the project(Sec,]044,Bmine s
nsand Professions Code:)The Commaora PERMIT ISSUANCE
License Lawdommotapply toanownerofpropeny,whobuildsorimprowitherton,and
who cunnucm for such projects with acommmtogs)licensed pursuant totbe Conuactora
License Law. AUIER-DRAIN&VENT-WATFA(EA) FEE SUMMARY
❑ 1 um exempt under Sec. .B&P C fm this rescan BACK FLOW PROTECT.DEVICE SANITARY SANITARY YN
Owner Dote RECEIPTp
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihcreby effrm thatlhavescenifcnte of consenva eelGinsurt,orettrtificese of FIXTURES-PER TRAP RECEIPT'# a-
covers 11 emplcneationlnsumncemoccrtifiMcopy thertof(Sec.3g00,lah CJ which PARK FIiE Y N
rovers ell cmplOyee'satndenhis permit. GAS-EA.SYSTEMBUILDING IVISI DIVISI L4
Policy#
-IINC.4OUTLETS RFEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCH[CK FEE
❑ Ce !rod
copylembyfumishW.
❑ Ce.ted copy is�,led with th city inspection division. GRP.ASE(INDUSTRL WASIf INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompletedEthe permit is far..hundrW dollars($IN) SEWER-SANITARY-STORM EA,200FT. ENERGY FEE
or less.)
I certify that in she perfomunce of the work for which this permit is issued,i shall WATER I[EATER W/VENTIELECTR
who employ soy No.in any manner or,os to become subject in the Worker% PAID
z Compenteatmalawsof California. Dae WATER SYSTEMITREATING Dare Receipt#
Applicant
O0 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
ybecome subject to the Workers Compensation provisions of Ne Labor Code,you must
a ; foMwith comply with such Provisions or this permit shall Be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz 1 hereby affirm that them is a ronstomfion tending agency for the perfonnmtce of TOTAL: ELECTRIC FEE
O the work for which thio permit is issued(See.304/,Civ.CJ
Ixndera Name
O Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that 1 have recd this application and stare that aBitn above information is
>" 0.W. cortem.Iugtec to comply MECHANICALME
pywith all city end county rnNnencn end there Iowa relaring to PERMIT ISSUANCE
�" ) Wildingcunamelion, it hereby authorize hep ocrustiwamifthis citymrnlet.,.Ne CONSTRUCTIONTAX
U 7, above-mentioned mperty,for inspection purposes. ALTER OR ADD TO MECH,
Ow w,indemnify a d kap honrdc.the City of Cupenina against
liabilitic and exist. swhichan manyway meagalnst 'd Ci AIR HANDLINGUNIT(TO IO,000CFM)
in con f c 6 nti print. It
HANDLING UNIT(OVER 10,00)CFM)
Signam ofd lican on or 11 Date EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO IN."BTU) Date Receipt#
Will the applicant,or future building netapons them at,handle hazardous maerial
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Section 25532(a)R
EI Yu El No VENTILATION PAN(91NGLE R2SID)
ISSUANCE DATE
Will the applicant mfuture buildingmcupentuse equipmenmrdcvices which<mit BOILER-COMP(HIP OR 100,000 BTU) PAID h.m..s air ronteminm0 as dented by he Bay Area Air Quality Management BOILER-COMP(OVER IN,"BTU)
�Oistri<tP
r ❑Yes ❑No - NEW RESIDENTIAL MECH.-SQ.FT. APR 1995
I have read the hazardous materiels requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand Net
if the building does not currently have a tenant,that it is my responsibility to notify But - CITY Ur UUYIjVN
occupant of the reluiremat which must he met prior in issuance of a Certificate of
Occupancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE