27735 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUMBIN�ry cAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 27735
Jib # :BUILDING PROJECT 11) NTIFICATION�-
BUILDING ADDRESS: ZAAP, SANITARYNO. APPLICATIONSUBMITTALDATE
1_
UNIT# LOT#
NERS NA F.: PI CO R TOR'SN M � LIC NO:
SEC CONTROL k
12 X&
•A CHRECT/EN OUSEG���__ LIC NO ADDRUST ❑
I
CONTACT: PHONE: Gr# 'R 3A'V T 'p.a V x C° T °'`''
QTIli ' ' EEBGTRI@ PERMITr + "'+' FE6 f 4 r z.n n n&aR"BUIL'DI'NG PERMIT INFO-
:S'&W'R &S'#e " `'" Vb "Uh BLDG ELECTLUMB MECH
PERMITISSUANCE El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
❑mz Ihereby affirmthat lam licensed underpmvisionsnfChapter9(commacingwith JOB DESCRI IO`N
�00 _redion]000)of Division 3of the Business and Professions Code,and my license is in PANELS C�
y�
rent and off of
MQZw DinenseC Co.M��/ , UP T0200AMPS
Q L Dine,�� Covector _AK'C_ 201-1000 AMPS
z Onv' ARCHITF.CT'SDECLAR TION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.UT.
C)Z—Q ' use a re emds.
W SIGNS ELECTRICAL
q�'y�.�.I Lmenaea of slam 4
La�6 OWNER-BUILDER DECLARATION SPECIAL CIRCU OWSC.
OyU I hereby affirm that I am exempt Immune Contmcmis License Law for the
W 30.y following reason.(Section'1031.5,Businassand Professions Code:Any city or caraty TEMP.METER OR POLE[NST.
which requires a permit to conmma,site,improve,demolish.(it repair any structure
prior to its issuance,also requires the total itual for such permit to file u signed statement POWER DEVICES
1 A CO that he is licensed pubmaauo the provisions of the Convectors License Law(Chapter SWIMMING POOL ELECTRIC
0.00. 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade) VALUATION
a, or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURPS
< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500).
Q NEWRESIDENTIALELECTR .FIL STORIES TYPE CONSTRUCTION
W ab ❑ othe wrk,an thesimulaermyemplayedores ofwedforsaei(Sec.7mm.Business
y will do thewons andthe he Conelsnntintendese La a does not
to an Business
and Professions Code:The Cmathime s License Lew does not apply m a owner of
is
omoeny who bui Ids tar improves thereon,and who does such work hi mself ed through his
owiiemployees,provided improvement
neyear fcomp[kreJ theo owner-
OCC.GROUP RES.UN11'S
bases bander whe illhabuilding tebrier f,mvii issoldhe within year ofc prove completion,the of TOTAL:
M1uilJer will have the burden of oroving that he did not build or improve for purpose of
sole) 4My iiic a
nr < .
❑ Lie rofthepmperty,amexdusivelyconvactingwithlic<nsedconhacromm QT�Y['* < byPLUMIi1NG PCRMIT,'•�dyf Q.FEE, ..*, FLOOD ZONE APN
consumer thepmject(Sea.9044,Business and Professions Cod J TTe Conlrecmrs 55.. ..-. ,
License Law does notapplymanownerofproperty whobuilds orimprovesthereon,and PERMIT ISSUANCE
who contracts forsuch projects withacontracmgs)licensed per strummthe Contracmis
License Law. ALTER-DRAIN&VENT-WATER(EA) =F i ,FEE SUh'TMARf "
❑ I am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE O SIDF.FEES
SANITARY Y N
Owner Date pRA1NS-FLOORROOF, COND. RECEIPT#
, , , .
• cove WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Iherehy affirm thatlheve ncertificete of consenum self-insure,orncertificute of RECPT#
Workers'Compeandon Insurance or a oertiBed copy thereof(Sec.3800,Lab C.)which FIXTURES-PER TRAP EI
PARKFEE Y N
rs ell employee's under Nis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT,
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is herehy famished.
❑ Confined copy is Bled with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nmbe completed time permit is forum hundreddollsra(SHad SEWER-SANITARY-STORM EA.2oripr. ` ENERGY FEE
IPz
arle".)
certify that in the performance of the work for which this permit is issued,l shell WATER HEATER WryENT/EI,ECI'R
not employ any person in any manner so as to become subject ro the WorkersPAID
Compensatina Ltwsof Celifomia. Data WATER SYSTEM(FREATING Date Receipt#
Applicant
Z 0 NOTICETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT.
p s ou TOTAL:
Lo� become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked BUILDING FEE
aQ CONSTRUCT! YLENDING AGENCY SEISMIC FEE
Uthat there iss nswcunn lending agency for the performance of
z I hereby affirmT
O the work for which this a ed(Seo.3099,Cis.C.) TO ELECTRIC FEE
w FLeduaAame yy •-, xCL < p
Lenaders Address QTY fV -P MEyCHANICAL'I'ERMTPSr s .%♦+FEF -} 3 PLUMBING FEE
C U 1 certify that-IT ave inal this pplication and state that the above information is &'T #$ 4 ° `
6i correct.I more to comply with all city tadcoamyoNnanees and state laws mount,to PERMIT ISSUANCE MECHANICAL FEE
I7n above-mentioned
construction,and hereby atrunize representatives ofthis city to enter upon the CONSTRUCTIONTAX
U a property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify cod kap formless the City of Cupertino against
lishilities,judgments,costs andexpenseswhich may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence or the granting of this permit.
AIR HANDLMG UNIT(OVER 10,000 CPM)
Sigamure of Appliaant/Coutraaor Date EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dale Receipt
Will the upolicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,0008'fU) TOTAL.
as M
defined by the Cupertino unici Code,Chapter 9.12,and the Health and Safety
Cale,9eefi 25532(a)1
11Yes o VENTILATION FAN(SINGLE REBID)
❑
BOILER-COMP(3HPOR I0000p BTU) a1 �SI�NCE A
Ttl
Will npplicumorfumtt ,
rebuilding o
upuntuseeyuiomentmrdevices whichemit P
M1vurdmus air DEC • �JQ
communma as d Med by the Bay Area Air Quality Management BOILER-COME(OVER 100,0110 BTU)
District?
•I ❑Yes Nu NEW RESIDENTIAL MECH. SQ,FT. 94
I have read the hazardous materials requirements under Chapter 6.95 of the C
California Health&Safety Code,Sections 25505,25533 and 25534. 1 undersand that
ifthebuildm,donot currently have a tenant,that it is my responsibility to notify the F.fl
'q t be met pdnr issuance of a Ce e, of
Occ
eti Dat TOTAL: ISSUED BY:
OFFICE