27163 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 'HN(;'EiR .CMT7APERMITN°. 27163
If APP CATION/PERMIT PLUMBING-MECHANICAL
BUILDING I3IVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: Qom/—j/ � \ \ r \ LOTH SANITARY NO. APPLICATION SUBMITTAL DATE
W UNIT#
OWN{;RS AME. HONE:^��,
CONTRACTORS NA E: LIC NO: NIC l.7COONTROLN
ANC]IITECT//ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE HGILDING PERMIT INFO
lrrp,JI _ BLDG LE P U H
(�F PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION ffiAPPLIANCES-RESIDENTIAL LOB DESCRIPTION
Q9z I hereby arm that l an licensed underprovisioes of Chapter9(commencing wirh
P100 Section 7000).&Division 3 of the Business end Professions Coda and my Have is in PANELS
faRf.raandeBa'. S�w�.
Fz,Wa# UP T0200 AMPg
License Class Li
m ooDoo Date Contraclm 201-1000 AMPS y@
OZ-0ARCHITECTS DECLARATION OVER 1000 AMPS ^ 5Q.PT FLOOR�1 ' 1� 103
0O,— I maderswnd my plans shall he used as public meords. p` VT\
P rn I:W SIGNS ELECTRICAL,Licensed Professional
4Cx G ma I. RUILDERDECLARATION SPECIAL CIRCUIT/MISC.
W 31,4. 1 hereby n. that I am exempt from the Coliona Ca License Isco for the
following recon.(gation]031.5.Business and Professi.v Cade;Any city mcounry TEMP.METER OR POLE INST.
`SES,vj which requires a permit to construct.after,improve.demolish,or repair any swetme
emts�p.7 prion.its isstmose,Amna,dirts theapplieent forsuch permit to file s signedsmement POWER DEVICES
W K
00 that he is licensed purumno We provision of the Commnor's License Law(Chapter
4 of 9(mmmencing with Section]000)of Division 3 ofthe Bminessand Profession Code) SWIMMING POOL ELECTRIC VALUATION
,!2 art Sechut tion 7031.5 by ttbercfmmmd'he baspermitmtheallegedexcmant to civiny l Platin of OUTLETS-SWITCHES-FIXTlIRF_S �1 \�
CZa Section 7031.5 by any applicant for apermit subjects the applicant mecivil penalty of L Sl
KTT ant more than five hundred Hollers(SAID).
F. ❑ I,axotonerofthepropeny,ormyemployaewim wegesmtheiraolecompenseGon. NEWRESIDENTIALELECTR _SQ.FT. STORIES 0 TYPECONSTRUMON
will dothe work,and the suucmre isnot iatendedoroffeced forsale(Sec.71F4,Business
and Professions Code:The Contractor's License Law does not apply tom owner of
property who buildsorimprovesthcramand shodues such workhimselforthrough his
n ro to ees,providedtha such ion OCC.GROUP RES.UNITS
c p y provld within
earofimpletiod themalL
however.Neave[Ile burden of emeinishathwithinoneyea or improeficar thrower- T
builder will have the burden of proving that he Jitl not build or improve for purpose of
sa]e.),
❑ I,asownerofthepropeny,umexclusivelycomractingwithlicensWcommm.oar QTY. PLUMBING PERMIT FEE FLOOD ZONE. APIA
.mama the project(Sec.7014,Business and Professions Cade:)The Commerce, PERMIT ISSUANCE,
License Law does not apply m m owner ,o f property who builds or improves thereon,and
whoc.nracts forsuch projects with a cumrmmr(s)licensed pursuant to the Contractor's IALTER (FA)
License law. FEE SUMMARY
❑ 1 um exempt under Scc. ,B&P C for this rcamn BACK I7LOW PROTECT,DEVICE: D'FEES
SANITARY V N
Owner D.— DRAINS-FLOORROOPAREA, RE.CEIPTN
. , , .
AT
WORKMAN COMPENSION DECLARATION SCHOOL TAX Y N
❑ I hereby affirm that l have a cenificate ofconknt to self-insure,or a certificate of MIXTURES-PER TRAP RECEIP #
Workeri Comem
pation lnsua
raaceoranifiedcopy thereof(See.3800,Lub CJ which PARK FEEN
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS 'I�
Policyp BUI G 1 1 NiES
Company GAS-EA.SYSTEM OVER 4(EA) PLANCIIF.CK FFO
❑ Certified copy b hereby furnished.
❑ Cetdfie4 copy is filed wiW Ne airy inspersion division. GREASEANOUSTRLWASTEllsO RCEPTOR GRADIN ILA Low
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS
COMPENSATION INSURANCE
('Ibis seelionmeeJ not becompletul ifthe permit is foromehutrdrcd dollanpilfO SEWER-SANITARY-Sl'ORM PA.200FT. ENERGY FEE
or less.)
I certify that in the performance ofthe work forwhich this permit is issued,)mall WATER HEATER W/VENT/ELECIR
not employ,my person in my manner so a to become subject in Ne WorkersPAID
Z Compensation Lawsof California. Date WATER SYSTEMRREATING Dae ettipt#
Applicant
Z NOTICETO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PINE. SQ.FT. TOTAL:
rQ) hcome subjecuo the Worker's Compensation provisionsofhe Labor Code.you..at
C4 ` forthwith comply with such provisions or this permit most be deemm revoked. BUILDING FEE
LQ A CONSTRUCTION LENDING AGENCY SEISMIC FEF. O
7 Z I hereby oflina that them is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this permit is issued(Sec.3097,civ.CJ
CI. Lender's Name PLUMBING FEE
Q U Lender's Address QTY, MECHANICAL PERMIT FEF.
I certify Nat 1 have reed this application and stns that the above infotmetian is 4 MECHANICAL FEE correct.legtatocomplywifiallcityandcoua tymdinancesandsmmlewsreletingm PERMIT ISSUANCE.
building construction,and herebyauthodze representatives ofthis city mercer upon the IV
CONSTRUCTIONTAX
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)ugrc.to save,indemnify and keep hamleas the City of Cupertino ugainst
Iiabiluics,judgments,costs said espenes which may in my way meme against said City AIR HANDLING UNIT(TO 10,000 CFM)
in cons eq fthe granting of this Q aa m,it.
s / �I 'p AIR HANDLING UNIT(OVER I0,00)CFM)
asm
Signareof Applicam/Contmcttorr I /� Date I EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,IX11)BTU) Date Raeipt N
Will the applicant or future building occupid acme or handle hazardous mnterial HEATING UNIT(OVER FOR"BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)1
El Yes El No VENT'ILA'TION FAN(SINGLE RCSID) \
BTU) V" QO
1$$U(kN�EUATE
Will thea applicant or fvwrcbuildin quip100,000pp goecupantuue memordevias whichemit BOILER COMP(JIIP OR I
hamrdous air caruminann as defined by the Bay Areas Air Quality Management BOILER-COMP(OVER 100,000 BTU)
nt ❑ JAN 24
D ]
sea Yee ❑No NEW RESIDENTIAL MECH. SQ.IT. 1000
t I have must the hazardous materials rquiremems under Chapter 6.95 of the JJJ
it the mil Health gdes ox elycur Cady have ons 25S05at it
and 25534.I q u,ntand Net Cary ser GUN11)
il'the building e no trim meats currently have u tenant,that it is my respnce of ry e notify the �!
O c rpant of the rquirements which mutt be met prim m issuance of s Certificate of
Occupancy.
Owner to mthonzed agent Date TOTAL: ISSUED BY:
OFFICE /