27851 APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OE CUPERTINO A,ri x-RLECTRTnU PERMITNO.
APPLICATION/PERMIT PLUMRING-MECHANICAL. O C•I
BUILDING DIVISION - 11_HNG PROJEC 1'IDENTIFICATION 851
BIIILDg•qIN'�O�AD��IIR�I1?SS: SANITARY NO. APPLICYHONSUBMGTALDATE
l/�y2Q � a.la•• &S UNIT#Y �n•1 /1 I! LOT# O ^
O Ra of/Gn Nom #111f 6000 CONTRACTQR�n:Br LIC NO: / 4-
��''JJ N/C CONTROL#
.ARCHITIiC'1'/IiNGINTER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
L //^ QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
^�e V a� e r `/'08 9�j'-6 PERMIT ISSUANCE BLDG ELECT PLUMB M��EgqCH
16
LICENSED CONd and Tpm'SDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
sz (hereby Divisiondust I rum 3 ofthnsedinss and isiesiona Ceter9(commencing with
UE full fon](KKBe f Division 3 of the Business end Pmfeuions Code.and my license is in PANELS �1 F
LL's full force and effect. IIPT02g1AMPS L\J
QL, Li,cme Class LIc.M
n<c,. Duro Conammr 201-1000 AMPS
1—,z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
zz o oi—p I understand my plans shall be used as public recants. OVER 1000 AMPS
r sn l=til SIGNS ELECTRICAL C 1,77
Q �,'j Licensed Professional
e. W U
OWNER-BUILDER from
DECLARATION CiumaION SPECIAL CRtCUR/MISC. ]rJJ
xa�dOyF 1 hereby affirm shat 1 am exempt from the Cosions Co e:Any Law forco the
u13 W m followingui es a (Semi nn construct,
t,mass and Professions Code:Any city or county TEMP.METER OR POLE(NST.
which requires a permit w conswm,cher,improve,demolish,m repair any swmua
�<2 'hat
slicensedpu mouttothethrovisi nsoftheComermiuoLicann Law(etement
POWER DEVICES
W lY p shat m is licensed pursuant so the)of Provisions of the Ce Busin ss License Lew(Chapter SWIMMING POOL ELECTRIC
o•io�G 4(commencing with Section]0007 ofDivisinn3ofthe Business and Professions Code) VALUATION /
or that he is exempttherefrom and the basis for the alleged exemption.Any violation of 011'TLETS-SWRCHES-FIXTURES
z Q Section]031.5 by any applicant fore pewit mbjmts the applicant to a civil penalty of /9 Sr 7 y0
not more than five hundred)offers(ES(ro). NEWRESIDENTIALELECR S .PT. 5/0
I,re own five he ycmp y g pe Q STORIES TYPE CONSTRUCTION
❑ propachine cy,orm to ed witbwe eformic(Ser.7om nseness
pLL, willdmhework,ande:The Cmdrsnmi License Lac,
formic ntapply.to an .,of
and Pn, h.tm Code:The Conthe..,License Law docs not apply lf an owner of
ownertywhmis,prsorimprovextherprove wtamenouctendelimwlfor Wovghhia
cmployces,pmvideJ that sucbimprovemrntsemnotimendedoroffcrW for We.IL ^ OCC GROUP EUNITShowever,the building or improvement is sold within one year ofcompletiou,the owner- TOTAL: 170,411builder will have the burden ofpmving that be did not build or improve for purposeofisle.).❑ I,mownerofthepmpcny,wnexclusivelymnuaetingwithlicerls nwcwnw QTY. PLUMBING PERMIT PEE FLOOD ZONE.
consumer the project(Sec.7(J44,Business and Professions Cade:)The Contractor's
License Lawdcesnat apply manownerofpropesy whobuildsormumovesthereon,end PERMIT ISSUANCE
whornnuans for such projects with aconvaclona,licensed pursuant todeConwemr's
License Law. ALTER-DRAIN&VENTWATER( I'LE$UMMARY- s
❑ 1 um exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE O SID FEES
SANITARY Y N
Owner Uma 15RECF.IPf M
DRAWS-FLOOR,ROOF.AREA.CONU.
WORKMAN COMPENSATION DECLARATION SCHOOI.'TAX Y N
❑ I hemby grim that l have a certificate ofconsent to self-insure,or a certificate ofRECEIP #
PI%TURES-PER TRAP
coversWorke1Cmnpoyes's CompensationInsurancethus Mira certifiW copy thereof(Sec.)800,Lab C.)which - ARK FEE Y N
ars ell employee's under this pewit. RECEIPT#
GAS=PA.SYSTF.M-I INC.40UTLETS
Policy p BUILDING DIVISION FFFS
Company GAS-IIA.SYSTEM-OVER 4(BA) PLANCHECK FEE
❑ Caddied copy is hereby famished.
❑ CertifiMwpy is filed with Ne ciry inspection division. GREASE(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSOR BASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is foronehundred dollars(SIM) SEWER.SANITARY-STORM FA.2tMIFT. ENERGY ME
or leax.)
I cosily diet in Ne performance of the work far which Nis Permit is issued.l shall WATER HEATER W/VENT/LLECIR
not employ any person in any manner as to become subject to the Workers' PAID
Z Compenxmionlswsof Cadifomie. Data so WATER SYSTEM/fRPAT{NG Dae Reccipi#
Applicant
� Q NOTICE TO APPLICANT:If,after making this Cenfficate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
Gobecome subject to the Worker's Compensation pmvisions ofthe Lothar Code,you must �5
�. , forthwith comply with such provisions mild,pemdt shall be domed revoked. BUILDING FEE OKE/
W r� CONSTRUCTION LENDING AGENCY SEISMIC FEE D
1 herchy affirm that there is a construction lending agency for the performance of
O TOTAL: ELECTRIC FEC
the work far which this pewit is issued(Sec.704],Civ.CJ g 6
O � Lenders theme
+ Lenders Address QTY. MECIIANICAL PERMIT FEE PLUMBING FEE
W1 certify that I have read this application and state that the above information is
a correct.l agree to comply with all cityand county ordinances and state laws relating in MECHANICALME PERMIT ISSUANCE •4
_ y builJing co.mar6on.and herebymm in representativesofthis ciry w annarupon the CONSTRUCTIONTAX
U Z aMwe-mentioned property for inspection purposes. ALTER OR ADD TO MECIL pv/
(We)agree to ev,indemnify end keep homeless the City of Cupertino agairxst
y liabilities,judgm nand expenses which may in any wayaccme aguinp acid City AIR fiANDLING UNIT(T010,000 CfM) /V
I.
consequenc Ne granting o 1 t.
��� er 10/11//S AIR HANDLING UNIT(OVER IO."CFM)
Sigm of ApplicunUContmmor �T7 Datata EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Will the applicant or future building minima store or hvrelle hazardous material IIFATING UNIT(OVER I W,9IXI BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Section 25532(0)4
12 Yes 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE CAC
Will theapplicsnwrfmltm buiidingmcupnntuuequipmenmrdeviceswhichentit BOILER-COMP(JfiP OR 19(1,000 BTU) k` C4 d U
hazardous air conundrums as defined by the Bay Area Air Quality Madmgement BOILER-COMP(OVER 190,000 BTU)
°''""' OCT 9
❑Yes ❑Nn NEW RESIDENTIAL MECH. SQ.FT. 19Q5
I hove read the hazardous materials regniremcnts under Chapter 11.95 of the C�1 1 v
California Health&Safety Code,Sections 25505,25573 and 25534.1 undarstvW That V Uk UurLiy-
ifthebuilthn lots cuwndyhaveasenont,thatitlsmyresgmsibilitytonotify Ne x'
mcup t req y�ts which must be met prior w issuance of a fenifiesce of
°4
er m atuffiariml e� Date TOTAL: ISSUED BY:
OFFIC