27671 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11ILI11Nli-RLK1"PRICM PERMITNO.
APPLICATION/PERMIT PLUMBING - MECHANICAL 27671
BUILDING DIVISION BUILDING PROIECI' IDENTIFICATION
1� 1'tI`
N/C
El
CUNfKUL,4 1
\RCI IITF. T/ENGINEER: LIC NO:
ADDR S:J /
,RVlrna Li / o- a
'ONTACT: PHONE:
Q'fY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH/",–
El El E]
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hmnbyaffirm tho l am licensedundcr provisionsofCbttain g conunr.a., with
APPLIANCES -RESIDENTIAL
JOB DESCRIPION
Section7(XX)) of Division 3 of IM1e Business and Professions Code, and my license is in
PANELS
full force and effect.
Liecme Class LIc.a
UPT02MAMH
`
Date Co..'
ARCHITECTS DECLARATION
201 - IM AMPS
SQ, FT. FLOOR AREA
OVER 1000 AMPS
1 understand my plans shall be used as public records.
SIGNS ELECTRICAL
U .... ed Professional
OWNER -BUILDER DECLARATION
SPECIALCIRCUIT/MISC.
1 hereby affirm mat I am excreter fr. he Cmeraaor'a mi Law the
TEMP. METER OR POLE MST.
fall—mil ceson.(Secline ]O1 LS, Business and Profession. e: Any city ar <n my
which requires a isc mit to comtruG. alter, improve, ish, or repair any some re
primm its issuance, also requires lbeapplican ch permit to file. signed site at
POWER DEVICES
that he is licensed purmam m the as of the Colnmmu s License Law (Cha ter
Y (commencing with Sec' of Division3of the Business Brut Pro(essionsC e)
SWIMMING POOL ELECTRIC
VALUATION
or that he is exec It ercfrom and the basis for the alleged exemption. Any smart of
Smion]03L5 any applicant foraprrmit subjatthe applicenno «civil pen yof
OUTLETS - SWITCHES - PIXTURES
nm moreman etheprod dollars ($500).
❑ Trasoothewn nndtemucty.armycmpbyecswithwedfroa ldei(Sce. comps cion,
NEWRFSIDENTIALELECfR_SQ.FF
STORIES
TYPE CONSTRUC
will do the woo and the stmctumisnotintended tiroffemdforsele (Sec.]0,,,
.'ad Prom"io s Core: TM1c Contracesr's i se Ln does not apply to an netof
pro, who uild.ori rove therto dwod such work himxlfor ughhis
employ s, pnrviJ J M1at sn M1i lintendedor offered sale. If,
OCC. GROUP
RFS. UNITS
TOTAL:
buweveq the u 1 cy,arofcompletion heawncr-
builder will use In Ne p hedid nu buil)or imprevef purpose of
m
QTY. PLUMBING PERMIT PEE
FLOODZONF,
APN
sale.).
❑ Lasa ernfthe r ny,amexewsivdycono.alm.wimlice a tars to
nstmet th project . e ]IM,, Business e d Proressi Con tors
License Law ors not pp man owner ofp 1'}I=ty_whole r sthere ,.ad
whocommc fnrsuc jeers xlme cpjIiac ��S)ioeAied Pu u t Con has
License haw. ` {{((„//
PERMITISSUANCE
ALTER - DRAIN&VENT - WATER (FA)
IlE SUMMARY
❑ 1 am ex pt undo Sea \ D & P C for thi rt o
J
BACK MOW PROI'ECf. DEVICE
F[ -.US
SANITARY
SANITARY Y N
RECEIPT at
Owner Uate
DRAINS -FLOOR,ROOF,AREA,,OND.
WORKMAN COMPENSATION DECLARATION
SCHOOL TAX Y N
❑ Ihcmby.f thmlhaveaeeni , eeam"arof
Worken'Compens urtmermwccrtiRed copy thereof S sx.3X0i,Lab C.)which
rs ell employer's under this permit
Policy M
FIXTURES - PER TRAP
RI.CEIPIp
PARKFEE Y N
RIVISI I' p
GAS - FA. SYSTEM-] INC., OUT
BUILDING DDIVISION FEIS
Company
GAS - EA. SYSTEM -OVER, (EA)
PLANCHECK FEE
❑ Certified copy is hereby funlisbed.
GREASHIINDUSTRI, WASTE INTERCEPTOR
GRADING FEE
❑ CeniEW copy is Eled wiW thin city inspection division
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
SOILS HE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20017.
ENERGY FEE
Missection ncednotbecampleted iftheprrmitisforonebmn dallm($]M)
or less.)
WATER HEATER WNPTBELECIR
I certify that in this perforrouni the wmk for which this .I, is irsurd. l shall
not employ any person in any manner so as to become .subject m the WorkcK
PAID
WATHRSYSS'IEMITREATING
Cnmpcnmtionlnwsof Califamis. Date
Dale Receimal
Applicant
NOT ICIE TO APPLICANT: IL after muting this Certificate of Exemption, you should
NEW RESIDENTIAL PLM. SQ. FT.
TOTAL:
hecoms subject o me Workds Compensation Provisions of the Labor Cale, you must
forthwith comply with such provisions or this permit shall be domed revoked.
BUILDING FEE
SEISMIC FETE
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem is a construction lending agency forme performance of
in, work for which this permit is issued (Sec. 3097, Civ. C.)
O
ELECTRIC Rif:
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I.cnder's Name
Under's Address
I certify that 1 have mad this.pplication and sm. that the above information is
red. Iupon, it) comply with all city and county ordinances and state laws relatingm
PERMIT ISSUANCE
MECHANICAL FEE
building construction, and hereby amhmiu representatives of Nis city to enter upon the
move-mnsioned property for inspection purposes.
e
ALTER OR ADD TO MECII.
CONS'TRUCT'ION TA%
AIR HANDLING UNIT (TO 10.000 CFM)
(We) agree 1. nave, indn J send keep M1atmless the City of Cupertino against
liabilities, rlay inany way accruragainst said City
Is
en nfmcoltstin pc inch
h /� ��
AIR HANDLING UNIT (OVER I0,000 CEM)
1 1A font' mctor Do.
gna urco pP
EXHAUST HOOD UVIDUCD
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
HEATING UNIT (OVER 1W.000 B'I'U)
OTAL
Will the applicant or future building occupant stare or handle ba'isNous material
st Acfincd by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
ILA DON FAN (SINGLE RESID)
Calc, Section 25532(a)?VENT
C1 Yes ❑ No
ISSUANCE DATE
Will theu Beam oficame building trace mrdcviccs which emit
ry g by qea
BOILER- COMP(3HPOR 100.000 BTU)
havmJous air conuminant ss droned by the Bay Area Air Quality Management
the Air
BOILER - COMP (OVER IW,tXXI BTU)
p,
District?
LI
NEW RESIDENTIAL MF.CI I. SQ.IT.
Cl Y. 1:1f
YNo
� �'Y e 0
1 have read IM1e limardous materials reetuircnwnls under Chapter 6.95 of the
California Health & Safety Cade, Sections 23505, 25533 and 2553,. 1 understand that
If the building docs not currently have a tenant, that it is my responsibility to notify the
L14
tv
N P
of the requiremelns which must be met Prior to issuance of a Certificate of
% o/
ooccupant
crapanq.
ISSNEU BY: //N
Ow ........ hmicrdagcnt Data
TOTAL: