27209 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINOinumnima PLUMBING." " PERMn'NO.
BUILDING DIVISION /T ^O(I
APPLICATION/PERMIT .MECHANICAL G L J
BUILDING PROJECT IDF,NI IFICA'TION
BUILDING ADDRESS: ` �� /�►�1 SANITARY NO. APPIACCATIONSUBBMI TALDATE
W�`O L,J la.�� UNIT# \ LOT
OWNERS NAME: ONE: CONTRACTOR'SNAME: LIC NO: �l
8 ,57ra N/C CONTROL#
• ARCHUEC'IANGINEER: LIC NO: ADDRESS: V lJ ❑
CONTACT: PHONE:
to
�s �J QTY. ELECTRIC PERMIT PEE BUILDING PERMTT INEO
azF C.UU �. 98s'=6D6 PERMITISSUANCE B_Lg0 xsfy PL� MECII
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �P}
JOB
DESCRIPON
ozz I herehYaffimthat lamlicensedunderpovisiospter9(comencingwiN
1400 Seen.
dision3africe Business end ProfessionsCode,anxiety PANELS
fallfamaitff.
QW License Class Lic.# IIP T0200 AMPS
m y hate Connote 201.1000 AMPS
Z�yZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 I understand my plans shell h used as public amrds. ^• ' � #�
a J SIGNS ELECTRICAL / c L'f�
ad , Licensed Professional J
N= < OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xa C'U 1 hereby offimt that 1 am exempt from the Contramars License Law for the
W : y following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
t, to j which requires a permit to construct,ear,improve,demolish,or repair any structure
}2 pd.,o its issuance,also ne,ines theapplicaa for such permit to fileesigned suenant POWER DEVICES
MW OP. 9(commencing with Section 7")of Division 3 office<0 that he is licensed pursuem to Ne provisions of the Contractors License Law(Chapter
aXpBusineasand Professions Code) SWIMMING POOL ELECTRIC VALUATION
W—o, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of 1 /a$/t 406
tZ¢ Section 7031.5 by any applicant far a pertnitoubjects theapplicam in.,fell permit,of OUTLETS-SWITCHES-FIXTURES 1115/v(!V�
EFD Imort than five hundred delta.(1500). NEW RESIDENTIAL ELECfR —SQ,Pf.
K o n❑ I,osownerofthepropeny,ormycmpinyeca with wegesmtheirsule<omNamed., STORIES I TYPF,CONSTRUCTION
y moi= willdo the work,and theatmmurt is notimended oraffereA forsale(SecJ044,Business
and Professions Cole:The Contractors License Law does not apply to an owner of
property who buildsmimprovestheaan,sand whodonauchwod himselforthmugh his OCC.GROUP RES.UNITS
wnemploycea,provided that such imprawememsarenot imendedoroffetedforeale.If,
however,the building or improvement is sold withinone yesrof completion,Ne owner
builder will have the burden of n that he did not build m improve for f TOTAL:
provi g p puryouo
le.).
[II,asowneroftheproperty,amexclusivelyeonvactingwiNlicemedconwctorstn QTY, PLUMBING PERMIT FEE FLOOD ZONE "N
construct the project(Sec 7044,Business and Professions Coded The Cminuche'e
License lawdoesnm apply to an ownerafprepertywhobuilds orimproves therwn,and PERMIT ISSUANCE
whocnmumsforsuch pdjats wiNaconvaelods)licensed pursuanuo the Conwetor's se Law.
License
ALTER-DRAIN&VENT-WATER(G) PEE SUMMARY
111 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE O TSIDEEES
SANITARY YN
Owner Data RECEIPT#
• DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION $CHOOLTAX VN
❑ Ihcrchy affirm thetlheve accnificem ofconum gulf-ins......cenificareof RECEIPT#
FIXTURES-PER TRAP
Workers Compensation lmurancemacrniBM copy therrof(Sec.3800,Lab C.)which PARK FEE YN
cram All employee's under Nis permit GAS-PA.SYSTEM-I INC. OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-PA.SYSTEM-OVER4 GIA) PLANCI IECK ME -2
Iti
❑ Certified copy is hereby famished. LV
❑ Ccnificd copy is filed with the city impaction division. ass—
GREASW/ DUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGRFASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompletedifthe permit is foronshundad dollars($100) SEWER.SANITARY-STORM EA.20gFT. ENERGY FEE
m less)
I certify that in the performance ofthe work for which this Permit is issued,ishan WATER HEATER W/VENT/ELECR
nm employ any person in any matter so ex to become subject to the Workers' PAID
Conarmadarlawsof Califamia. Date WATER SYSTEMIREATING Data ReceiplN
z Applicant
z 0 NOTICE TO APPLICANT:ILaftermull,.Ids Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL;
.0
. become subjecto the Workds Compensation provisions office Labor Code.you must
a > foMwith comply with such provisions or this pethermalFE
df shall be decal awaked. BUILDING E
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby aBlred that thea is a commuction lending agency for Ne performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
lT. P lender's Name
UPLUMBING PEE
U lender's Address QTY. MECHANICALPERMIT FEF. L
LI ecnify that I have mad this application and sum IMI the above in(armation is MECHANICAL MEmecf. legrce to with all city and county ordinances and emu laws alatingm PERMIT ISSUANCE L
ca!) building construction,and hereby madames representatives ofthis city theater upon the CONSTRUCTIONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of CLpenino egairut tv
lirbilities,judgmems,cogs and expenses which may in any way accrue against said City AIR I IANDLING UNIT(TO ilf"CPM)
in cont ftha granting of this perm it
�S AIR HANDLING UNIT(OVER 10.000 CFM)
Signature of Applicant/Contmcn Data EXHAUST HOOD(W/DUCI PAID
HAZARDOUS MA RIALS DISCLOSURE HEATING UNIT(TO I0d,000 BTU) Date Receipt at
Will the applicant or fair.building occupant start or hmWle haasrdoaa mmed.9 HEATING UNIT(OVER IIp.IXIp BTU) TOTAL:
os defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Code,Sermon Vica ❑No
u)1
1:1 Yes VENTILATION FAN(SING LEREBID) �.
ISSUAjx,`C�DATE
Will the applicant or future building occupant use equipment devices which emit BOILER-COMP(SHP OR 10,1100 BTU) II7f'"' FF�IID
hunerdom nit contaminants es defined by the Bay Area Air Quality Management BOILER-COMP(OVER• IN,"BTU) JAN
o Dinner? JA 2
❑YeEls No NEW RESIDENTIAL MECH.—SQ.SQ.PT. 1f1(1JJJs
rem
1 have ad the haaanlous aterials requirements under Chapter 6.95 of the Cly
California Icalth&Safety Code,Sections 25505,25533 and 25534. 1 understand Nat OF I-'Urth NU
if the building does not currently have a tenant.that it is my responsibility to ngtify the
cveupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
Owner or authodaed agent Dau TOTAL: ISSUED BY:
OFFICE