27008 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 27008
.1.111. i-b..U11 xR`A1 PHRMI'TNO.
APPLICATION/PERMIT PLUMB ;-MECHANICAL
BUILDING DIVISION IIUII,DING PROJF,C'I'IDF;NTIFICAI'ION'
BUILDING ADDRESS: f. /t SANITARY NO. N'%.ICA ION SUBMITTAL
..) �� Irl✓ vF�l UNITa LOTa
O SNA l; PHONE: NTRACfORS C. LIC NO:
k(_ile u�f'e)a�II'w't- ��Ls[r Its, �C I C�y J NIC )NTROL
W` ARCHI'IECr/ENGINEER: LIC NO: ADDRESS pf / ❑
CON'1'ACI': PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEF,
BLDG ELf?C'1' 'qMI?CII
PERMHASSUANCH ElE
LICENSFiD CONTRACTORS DIiC1.ARA'I'ION APPLIANCES-RESIDENTIAL
p 7 ON
Ihereby of res that l am licensed underprovisimas ofapler 9(commencing with IOD UL^SCRIPI'1
;+100SectionManor Division] rbe Business and Professions Code,and my license is in PANELS
Fy-PI1_1-- ftillorceendeffoe"
FQz� License Clea Lic.p UP TO 200 AMPS
N=y Umc Commnor 201-1000 AMPS SQ.IT.FLOOR AREA Sm.FT.
'LOyZ ARCHITECTS DECLARATION OVER I"AMPS
oz-0 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
Qy2j Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CHICUR(MISC.
od06 U 1 hereby affirm that I am exempt from the Contractor's License Law for the n
m3u-vf—i following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. jO _ - -, •11 j'l It '�" 17
Ft_OyQ which requires u pemtit m ctrmwet,ober,improve,demolish,m repair any structure ..1 ,I✓ 1 /�,(1 I
CWQ2prior m its ismunce,also thev applicant lar such tto file a signed POWER DEVICES I (jri\Ivy\
p quires PP pcmti gnc �-_
;yCpO that he is licensed pursuant to the provuinns or the Contractor's License Law(Chapter SWIMMING POOL ELECTRIC
L ol'e� 9(amm�mncrng whM1 Section]THIO)of Division3nflbc Buslnces unJ Professions Code) ' _. Af.UATION
Zr Srthw h731.5b anyapplicant
ppmmand the permit subjevsegeJesemptto rivilprml,of j{ v
'Y Section 7031.5 by I' tfura t subjects @eapplicant oucivil h f OU'I'LEI'S-SWITCHIiS-FXTURES
F Z Q Y any app man panni su lac spermy o
not mese then five hundred dollars($SW).
�zG NEW RI31DIiNT1A1.ELECfR SQ'FI`.� STORIES TYI'fiCONSTRUCI'ION
Wm El hnsnwnvnfthe prmpeny,ormyemployeeswirh wagcsuatheirsolecampensation,
d3— will do the work,andthe structure is not intended uroffered foranle(Sec.]044,Business
and Professions Code,The Commit License Law done,not apply to an owner of
propeny who builds or improves thereon and who does such work himself or through his
ownemplSyees,provided thatsuch improscummesare not intendedorofferedforsaw.If.
OCC.GROUP RES.UNITS
however,the building or improvement is sold within now yearafcompletion,the owner- TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
idle.). QTY. PLUMBING PERMIT IEE FLOOD ZONE APN
❑ L m the pr jet Sec.7 44.Bu mess Ind Professions
s Claim)
Th comnmors to
License the project(Sec. ,an o Business and%ufessions Cmk:)The Contractor's PERMIT ISSUANCE
License law does not apply to an owner of%npcnY who builds sur improveahercon,and
whucommets for such projects with acomractorm)licensed pursuant to Connector's ALTER-DRAIN&VENT-WATERFA
License Law. ( ) FEE SUMMARY
❑ 1 nm exempt under Sec. .B&1'C for This reason BACK FLOW PROI'HCT.DEVICE OUT. E 11-1
SANITARY YN
Owner DateDRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby nflirm that l have a cerificme ofconsentto mlf-insure.or u certificate of FIXTURES-1'IiR'I'RAP RECEIPT#
Workers Compensation Insurance or a cenifed copy therm((See.3800.Lab C.)which PARK IEE Y N
coven all employce s under this Permit. GAS-FA.SYSTEM-1 INC.4 OUTLETS RE
Poll,a BUILDING DIVIVISSIONION
ZEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cer ified copy is hereby famished.
❑ CmifiW copy is fled with the city inspcaion division. GREASUINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS IEE
COMPENSATION INSURANCE.
Obis section need not be completed if Ne permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT." ENERGY FEE
or loss.)
I verify that in the performance ofthe work for which this Permit is issued,Isha11 WATER HEATER W/VENTMLECTR
not employ any pecwm in any manner so as m hecome subject to the WorkersPAID
Compensation Lowsof Califomra. Dam WATER SYSTI!M/L'RHA'I ING Date Reccipta
O Z Applicant
0 NOTICE TO N'PLICAN'1:If.ufmr making this Cerifemeof l?xentption,youshould NEW RESIDER'I JAI,PLMIL SQ.FT. 'IO'I'AL:
F (� be, on,ibjem mine Workers Compensation provisions of the Labor Code.you most
> norm,ith comply with such provisions or this permit trial l be deemed revoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm thauhem is a construction lending agency for the perfomtmce of
`U 'Z the wfor which this permit is issued(Sec.309].Civ.C.) TA ELECTRIC FEE
U ork Leni Name PLUMBING FEE
u' F Lenders Address QTY. MECHANICAL PERMIT FEE
U I roily that 1 have read this application and solution the above information is MECHANICAL FEE
>" W comet.I agree to romply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
f•-' building cnnslowden.and hereby maborimmpmmotatives ofthis city wenterupon the CONSTRUCTIONTAX
U Z above-mentioned propery for inspection purposes. ALTER OR ADD TO MECH.
(Wc)agree to save,indemnify harmless the City of Cupertino against
liuhilitics,)uJSan t.c tandexft ¢hes inunywaymcrueegvirim,odCity AIR HANDLING UNIT(TO 10,100 CFM)
�mctltc In n #ming pPthiq.Plmtil. r _ �4 AIR HANDLING UNIT(OVER Iggq CFM)
/��/�/L/� (/J P,XHAUS'f HOOD Sign re of Applicant/Cn Dam PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt a
Will the applicant or future building necupamnorc or handle Intimidates material HEATING UNIT(OVER 100.000 BTU)
f n
as deed by the Cupeninu Municipal Cede,Chapter 9.12.and the Health and Safety
Cede,Section 2532(m? VENTILATION 17AN(SINGLE RFSID) — A 911,
❑Yes ❑No
U ISSUANCE DATE
Will theapplicarmfutumbuildingoccupamt umequipmentordeviceswhichemit I BOILER-COMP CHIP OR 100.000 BTU) {� buy
®Nom air contaminants as defined by thm
e Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) SF 16 199�a
SF
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hamrdous materials requitemems under Chapter 6.95 of the C(�Y UI" UUI'CMI ICU
Cifthe fund Ing tits&Safety Cade,Sections 255(15.25533 and 25534. 1 understand that
thebuilding Ames not currently Code haveaImam,I5, it istoy rcsposib1 unenotifythe
eupant M the reyaircntems which must be inn prior In issuance of a Certificate of
Onlor .
Owneror awnori+W agent Date TOTAL: ISSUED BY:
OFFICE