27683 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO � �ELMIR 11
BUILDINGAPPLICATION/PERMIT PLUMBING - MF,CBANICAL
BUILDING DIVISION IIIJII,DINCI'ROJKCTIDEN'I'IFICAI'ION
NO.
] 7 O /�
27683
G I of
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE:
.�a�a •`�{u
— -171DO R `\• UNITY LOTM
IVI�6Att
PHONE:
OWN. 'NAMFjI.
CO R'S ryAMi/S: LI
N/C
El
CONTROL p
Are 5
/W/ A/n�At `
A RCI IITECI ANGINEER: LIC NO:
ADDRESS
CONTACT: - PHONE:
QTY. '.-; ' ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECTPLUMB MI -CH
1PB ❑ ❑ ❑
I
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm thm [.,a licensed undaprovi%ions of Chapmr9 mornmemingwith
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS -
UP TO 300 AMPS
Section 7000) of Division 3 of rhe Business end (croons Code, end my liana is in
full force and ef9
License Class Lic.Y f
Dulc Conuacmr bl
RCHITECTS DE A TIO
I undersand my plans shall be used to public records.
�•�.T`K \(/vel iFr V
301 - 1000 AMPS
OVER I" AMPS
SQ. IeI'. I+LOOK ARBA
5/SQ. FT.
SIGNS ELECTRICAL
Licensed PnJ'cusa n d
OWNER -BUILDER DECLARATION
SPECIAL CIRCUEOMISC.
1 hereby aRmr that I am exempt from the, Common's License Law for the
TEMP. METER OR POLE INST.
following noon. (Section 7031.5, Business and Professions Code Any city or county
whluh requires a permit to construct, ulmq improve, demolish, or repair any steuctum
prior to itsissuance, also requires the applicam for such pemduo file a signed statement
POWER DEVICES
that he is licensed pursuant to the Provisions of Ne Contractors License Law (Chapter
9(commencing with Section 7000)of Division 3ufthe Business and Profession Code)
-.
SWIMMING POOL ELECTRIC
yphUATION
or that he is exempttherefrom and the basis for the alleged exemption. Any violation of
Setiun 7031.5b listed for ,sub'ectsthee he., m e civil alt of
by Pc0)i 1 Pp penalty
p �\V1
\\ \
� u
OUTLETS - SWITCHES - FIXTURES
not morethan fivehundreddollarsyemp.
YcmP Y 8 ,ansa
❑ I,asownaoHhe Propcny.orm to ccs with wa eaazdM1eirsolecom tion,
will Jothe won, Craand ft: a.,ffered for apply I. an wine, ss
of
nnJ Professions Code: Thc Conwnnr'a License Isw does nod apply m m owner of
TheCoreisnodi,Nicense Lav,
�
NEWRESIDENTIALELECIR S FT.
—SQ.FT.
� \ - gTOWES t
` _ \ \~ t)
TYPE CONSTRUCTION
\ t
l t \ '�
property who builds in improves thereon, and who does such work hdvadfor through his
on employees, pvidedthat such imare
provementsnotimendedoroffered foraale.If.
DEC. VRCjUP
RES. UNITS
horo
wever, the building or improvement is sold within one year ofcomplelion,Browner-
milder will have the burden of proving that he did nod build or improve for purpose of
arded.
❑ Lasownerofteproceny,umaclusivelyconvactingwitM1licenxdcm=torso
QTY. PLUMBING PERMIT r'
FLOOD ZONE
APN
Lmstrun the project (Sec. 704, Business and Professions Code.)'Me Commemr's
icense Lavedoe% not apply to auowncrufpropeny whobudds suimriners thereon.end
PERMIT ISSUANCE
whoconmet forsudUarm dwithtantmcmr(s) licensed pursuant mthe Contractors
License Law. _ -
ALTER -DRAIN&VENT - WATER (EA)
FEE SUMMARY
❑ I am exempt under $cc. . B ffi P C for this mawv
BACK FLOW PROTECT. DBVICE
OUT SIDE, LES
SANITARY Y N
RECEIPT is
Owner Date
DRAINS - FLOOR. ROOF,AREA. COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ I hereby affirm that l have acenificua ofconsem mself-insure, macertificateof
Workers Compensation Insurance ora certified copy thercof(Sri 3800. Lub C.) which
covers of employe '% under this permit.GAS-FA.
Policy M
RECE.IPT'#
FIXTURES -PER TRAP
PARK FEE Y N
RECEIPT,
SYSTEM -I INC.40I1TLET5
BUILDING DIVISION FEES
Company
❑ Certified copy is hereby famished.
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEE
OIEASBANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Ccnified copy is filed with the city inspxdion division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS TEE
COMPENSATION INSURANCE
SEWER -SANITARY- STORM Fit. 20017.
ENERGY FEE
This section need not to completed if the permit is for one hundred dollarsMOD
or less.)
WATER I IP.ATER W/VENT/ELECR
I cenifythminthe performance of the work for which this —it is ismset. I shall
not employ any person in any m es to become subject h, the Workers
abate so
PAID
Compensation Uses of California,
WATER SYSTEMITREAT1NG
Dale Receipt Y
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
NEW RESIDENTIAL PENCE. SQ. FT.
TOTAL:
(come oulbi to the Workers Compensation provisions of the Lehr Code, you must
forthwith comply with such provisions or this Part thal he deemed revoked.
BUILDING FIiE /1
SEISMIC FEE
CONSTRUC ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the perfmmunce of
the work for which this pamrit is issued (gee. 3097, Civ. C.)
TOTAL:
ELEC1RIC FEE
Leader's Name
QTY. MECHANICAL PERMIT FEE
PLUMBING ftiE
Lender's Address
I certify that 1 have read this application and state that the dowe information is
corned. l agree to comply with all city and county oMmances and state laws relating to
PERMIT ISSUANCE
MIiCf1ANl .5
buildingconswch as and hereby amhorin repiexnativesof thiscity to enter upon the
uhnve-meminnc ropeny for inspemion purposes.
ALTER OR ADD TO MECH.
CONSTRUCDONT
(We) agr m save, indemnify and keep harmless the City of Cupertino against
liabilities,j mena.cosa ex penseswAlchmaymanywayace eegeinst said City
AIR HANDLING UNIT (TO Hf000CFM)
in censer cc of the gra go tort ,� �S�
S
It
AIR HANDLING UNIT (OVER 10." CFM)
1' Y hI1NV
5 roof A,listinflCmarrarm, D
/ ^
HAJARDOUS MATERIALS DISCLOSURE.
EXHAUST HOOD(W/DUCTI
PAID
Date Receipt#
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT(OVER IW.000 BTU)
'ITJTAI-
or of...holdingCode.Camnoreo. handle hHealth and Steed
Will thebc Caliendo.
os defined by the Cupsnino Municipal Cada, Chapter 9. L2. and the Ilcehh vier Safely
VENTILATION FAN (SINGLE RESID)
Code Section 25532(a)'J
ClYes 1:1No
Will thea licanmrfumrc buildin tux tmdeviceswhimemit
pP gacuhe
BOILER - COMPIJIiP OR IIXI,IXq BTU)
IANQF.II],ATE
- I #J
BOILER IW.(XIO BTU)
Area Ain
hazardous air contaminants az defined by the Bay Area Air Quality Management
NOV
r,LaricR
20199
NEW RIi.SIDENTIAI, MECII. SQ, FT.
❑ yes ❑ No
A
1 have mad the hamadem, materials requirements under Chapter 6.95 of the
GJie building ocsom Safety Code, tlyhav atena55o5at it is and 25534. lityto neer that
if rhe building Jas nor currently have n stneem et o is my rtsance of ity ramify the
Cil Y iy�/�%�'
Ur �uYe�a
a
occuponof the rcyuimmcna which moa be ran prior m issuance of a Cenificnm of
upon
Occupancy.
V✓
ISSUED BY:
Owner nr uuthoriuJ ngcnt Date
TOTAL:
OFFICE