27695 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.USE SALL POINT PEN ONLY
CITY OF CUPERTINO 1m'D]Nf'-F1.. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. L
NUILD{NG PR()JECI'IDENI'IFICA'TION
pU1LU1NG ADDRESS: �) SANITARY NO. APPLICA'HONSUBMITI'ALDATE
SNIT M
LOT#3 I
OWNERST4 NAME: p{I pNll; r
ACTOR'S ,JF LIC NO: (�
NO:ARCIIIECIAiNGINF.ER: LIC NO: ❑AtJSCONTACT: PHONE: ECTRIC PERMIT FEE BUILDING PERMIT INFO
/� /a.� IfE� PLUMB MI;CH
p� omNCE PLUMBLICENSLDCONTRACrlmovo ECfARAT10N
-RESIDENTIAL
p00O&Z Ihemhyaffirmthion amlicenselt.,arovisiodsicas Code,and
mmenense withL�C..GROUP
TION
n100 Section]0007 of Division 3 of to Busirusa end Profusiora Cade,end my license is in PANELS
CU� full force and effect.
IQ„zW License Class Lick TO 2M , 1
N=y Date Contractor `�
000 AMPS
ZOrn�
ARCHITECTS DECLARATION $/SQ.FT.
O z r_❑ I undersand my plana shall h used as public records. 1000 AMPS
F'4 5 ELECTRICAL
Lwnsed Prnkssumul
p9Lax.CN OWNER-BUILDER DECLARATION L CIRCUIT/MISC.
W 3 e�6i.F 1 hereby affum that 1 am exempt from the Contranor's License Lew for the
W a O rn following reason(Section]031.5,Business and Professions Code:Any city or county METER OR POLE MST,—y which requires a permit to construct,alteq improve,demolish,or repair any structureprior to its issuance,alsoaquimstheapplicantforsuchpermirtorileasigmedsatement DEVICES� sThal he is licensed pursuant to the Provisions of the Contractors License law(Chapterk.LL 9(commencing with Seetion7")of Division 3 of the Business and Professions Code) ING POOL ELECTRICNWMV, or that he is exempt therefrom and the basis for the alleged exemption.Any violation ofppoevpentyoTS-SWITCHES-FIXTURESmore Nan five hundred dollars(5500).Lasowner fNeProperty,ormyemployees with wages astheirsulecomperawicn, ESIDENTIAL ELECIR _SQ.fT. TYPECONSTRUCTION
ill Jolhework,andtheswcmaianotimende oroffeadforale(S .70 ,Busiaeuand Professions Cale:no Conaacmr's License Law docs not apply to on owner of
propertywhobulldsor improves Hereon,and whodeessuchwork hi mselforNmugh hisILRES.UNITS
however,the buildingor improvement is sold within one yearofcompletion,theowncr-
builder will have the burden ofpaving Nrave Purpose of
al he did not build or im for TOTAL:
salcy P
❑ I,as ownerof the properly,am exclusivelyconhacting with licensed contractors to QTY. PLUMBING PERMIT FEL? FLOODZONE APN
cullowd the project(See.70col Business and Professions Code:)Tim Conlrsetor'a
License Lawddesnol applyto anowneroffamperty,who builds or improves Neteon,and PERMIT ISSUANCE
whOcontmcts forsuch projects wit a conuaaor(s)licensed pursmnt to Ne Contractors
License Law. ALT E]k-DRAIN&VENT-WA PER(EA)
❑ FEE SUMMARY
I am excmq under gee. ,B&P C for this reessm BACK FLOW PROTECT.DEVICE 61 E .1:.
Owner Dau SANITARY Y N
• WORKMAN COMPENSATION DECLARATION DRAINS-FlAOR.ROOF,AREA,COND. RECEIPT 0
SCHOOLTAX Y N
❑ —N—
Workers'
pffirmonInsurace ora cceteof consennterf(Sev.380r aaniflnm of FIXTURES-PER TRAP RECEIPTM
Workers Cmnpyee'snler this Insurance ora ficd copy lhemaf(S«.3800,Lab CJwhich PARK FEE Y_N
covers all employee's under permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#_Policy p BUILDING DIVISION FEES
Company
❑ Cenificd copy is heaby famished. GAS-EA.SYSTHM.OVI?R 4(EA) PLANCHECK IEEE
❑ Certified copy is filed with the city inspection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed Elbe .it is forone himalet dollars(SIM) SEW FJI-SANITARY-STORM P.A.200FT. ENERGY FEL
orless.)
I certify that in the peof-comnceoftha work for which this permit is issued,I shall WATER HEATER W/VFNT/ELECR
nut employ any person in any manner so as to become subject to the Worked' PAID
Compettsetionlswsof Califomis. Dote WATER SYSTEM/TREATING Dam Receipt 0 z Applicant
z NOT ICE TO APPLICANT:If,after making this Cultiicau of Exemption,you should NEW RESIDENTIAL PLAHL SQ.FT, TOTAL:
lesions,subj«t to the Workers Compensation provisions of the Labor Cade,you must
� ; forthwith comply with such provisions or this permit shall be deemed revoked. M�,E
E
IJ.I A CONSTRUCTION LENDING AGENCY
tz I hereby affirm Net there is a construction lending agency for the performance of
U O to work for whichthis permit is iasued(Sed.309],Civ.C.) TOTAL:Lenders Name
0 U Lender's Address Q'PYMECIIANICALPERMIT FEE EEI Certify tat 1 have read Nis application and sate Nmthe shove infomuuon is
correct.I agree to comply with all city and county ordinances and state laws relating as PERMITISSUANCE FEEbuilding construction,and hereby authorize apreamm uses ofthis city menter upon the
U Z above mentioned property for inspection purposes. ALTERORADDTOMF.CH. NTAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilitie999qqqsuuuyyyjudgments,costs end expeascswhich may in any way accrue against said City AIR HANDLING UNIT OG 10.01M CFM)
inc Ith�ng of�rmit.
0 � ,L^ —1* AIR HANDLWO UNIT(OVER 10,060 CFM)
Signamaof Applicam/C mmctor Data EXHAUST HOOD(W/DUCID
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT((0100.060 BTU) Deo RccciptM
Will the the Cupertino
or(more icbuilding rl C am store or huddle huza Health
and
Safrmaterial
as defined by the 32(a)?nu Municipal Code,Chapter 9.12,and the I1eJt end Safety HEATING UNIT(OVER 100,OW PTU) TOTAL:
Cak,genion 25532(a)?
❑Yes ❑No VENTILATION PAN(SINGER RISID)
Will the appliantar fwumbuilJing«cupant uuequipmentor devices whichemit
BOILER-COMP(3HP OR IM."BTU) 1 DATE
• D, 1.s air contaminants us defined by the Bey Area Air Quality Menngem 1 BOILER-COMP(OVER RK,0M BTU) DEC 21994
Diebin7
13 Y. El No NEW RESIDENTIAL MECH. SQ.IT.
1 have mad the hazardous tratetials requirements under Chapter 6.95 of the C�I T L.If 1aUYCIS I II�V
Culil'nmia llcalth&Safety Code,Sections 25505,25511 and 25534. I understand IAm
if the building Jces not currently have a tenant,et it u my responsty to notify Ne
occupant of the requirements which must be met prior m issuance of a Certificam of
OLCYp.Mfy. \�� /r��f�7
Occupnryutnnzed ogrnt – Date TOTAL: ISSUEDBY: \I TA
OFFIC