27271APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING - F,LE('TRU A ,
APPLICAT1ON/PERMPP PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJECT' IDENTIFICATION
PERMIT NO
27271
BUILDINGADDRESS:
10261 Ai—PA— Die �/ UNIT# LOT«
SANITARY NO.
APPLICATION SUBMITTAL PATH
OWNERS NAME: PHONE:
/I Y
NI / �
CONTRACTOR'S NAMIi:
_-34M7
N/C
❑
CONTROLa
�A Clfl'I IiCDF.NGIN IiR: LIC NO:
ADUI1E55: � �^l,��xa��11
CONTACT': PHONE-
QTY.
ELECTRIC PERMIT
NEE
HUILDING PERMII'.lNPO
@LDF El PLUMB ME❑CII
PERMIT ISSUANCE
TLQQ
LI CENSI?D CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed underpovvisions of Chapmr9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
PANELS
Up T02W AMPS
Section ermel)of Division3 of the Business and Professions Cale, end my license is in
furare, onJ eflc
License Class Loa. p
`
'- }l•`7u
Da - COm'S
� ARCHITECTS DECLARATION
D
t l understand myplans shall be used uspublicrecords.
OVER 1000 AMPS
OVER HIM AMP
SQ. IT. FLOOR AREA
1;/SQ. FT.
SIGNS ELECTRICAL '
Licensed Professional
OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
1 hereby affirm Nat 1 ton exempt from she Contractors License Law for the
TEMP. METFR OR POLE INST.
I following record. (Section 7 031.5, Business and Professie rs Code: Any city m county
which requires a permit to construct, ulter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed somement
POWER DEVICES
that he is licensed pursuanno the provisions of the Cantmmors License Law (Chapter
9 (commencing with Section 7") ofpivision 3 ofthe Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
err that he ix exempt Nerefmm pal the basis for the ul leged exemption. Any smadimof
Section 7031.5 by any applicant for o Permit subjects the applicant to a civil penalty of
OUTLETS - SWITCHES - PIXNRF,S
and mom than five hundred dollurs (S500).
❑ I. asownerof thepropeny ,ormyemployecswithwagesas Neirsolecompensation,
NEW RFSIDFN'ItAL ELECTR _SQ, FT.
STORIES
TYPECONSTRUCTION
will do the work, and the s onshore is not idendedoroff red for sale (Sec. 7044, Business
and Professions Cole: The Contrecwr's License Law does not apply to an owner of
property who bui IN m i mprov es therron, and who ddea such work hlmsel f or Nmugh his
own employees, providedthat such improvementsam not ineddedorefferm boards. If,
OCC. GROUP
NES. UNITS
TOTAL:
however. the buildingorimprovement Is sold within one year ofcompledon, thrown'
builder will have the burden of proving that he did not build m improve for purpose of
QTY.
PLUMBING PERMIT
PEI?
sale.).
❑ 1, as ownerufthe property, amexclusively contracting with licensed contractors to
FLOOD ZONIi
APN
consumer ale project (Sec. ?M4, Busidc s and Prnfcadmic, Code:) 'Me Contractors
Lice met. awdoanoapplymanownerofpropenywhobuildsorimpmvesthereen ,end
PERMIT ISSUANCE
who contracts forsuch projects with a coutmetoKs) licensed pursuant to the Committers
License Law. -
gLTIiR - DRAIN &VF,N- WATIiR (FA)
PTE SUMMARY
❑ I tee exempt under Sec. B & P C for this reason
BACK FLOW PROTECT. DEVICE
SIDEL •S
SANITARY Y N
RECEIPTM
Owner Date
DRAINS- FLOf3R, ROOPARG, COND.
,
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ IherebydOrm thatlhuveacenificmeofcon there f(Secure,or acertif which
Workeri Campensmiten lnsumnce oracenified copy Hereof(Sec.3g00, IabCJ which
RECIHPTp
F3XTURES -PER TRAP
PARK FEE Y N
GAS - PA. SYSTEM -11NC. 4 OU1 LEIS
covers all employee's tank, this permit,
Policy N
RECEIPT a
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM -OVVR 4 (EA)
PLANCHECK HE
❑ Cenifirtimpyisherebyfumishcd.
GREASUINDUS'I RL WASTE INTERCEPTOR'
GRADING FEE
❑ CenilieJ Copy is file)with the city inapettion Division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE
52q'IDSPn r' I�
SOUS HE
EWER =' SANITARY _ STORM EA. 2lgF1'..e
ENERGY HE
['ILissection need not he completed ifthe pennitis for one hundred dollars (SI(q)
orless.)
I certify that in she performance ofthe weak for which this permit is issued, l shall
IVATGRHEATER WryP /F.hCCT y II
not employ any person in may m gas m become subject to the Workers
aDate so
PAID
Cmmpenserioulawsof Califomia.
Applicant
WATER SYSTF: TI
P I i -
Date Receipt#
NOTICETOAPPLICANT: If, afar making this Cerificareof Exemption, you should
y_
NEW RESIDE SQ. FL
T TAL:
betook subject to the Worker's Copenaation provisions ofthe Labor Code, you must
fonhwith comply with such provisions or Nis permit shall le, deemed revoked.
BUILDING PER
0 �
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction leading agency for the pedumance of
the work for which this permit is issued (Sec. 3091, Cis. C.)
I.eoder's Name
TOTAL:
ELECTRIC PER
Leader a Address
QTY.
MECHANICAL PERMIT
PEE
PLUMBING FEE
1 certify Be, I have need this application and same Nat the above information is correct.
I agree to comply with all city road county ordinances and state laws relating to
PERMITISSUANCE
MECHANICAL . HE R
building construction, and hereby a flo rive representatives of this city to enter upon the
above - cannoned property for inspection purposes.
ALTER OR ADDI0 MECH.
CONSTRUCTON TAX
(We) agree as save, indemnify and keep tameless the City of Cupertino against
I imbildies, judgments. costs and expenses which may in any way accme against said City
AIR I JANGLING UNIT ('1'010,W1) CFM)
in ce nl ncc grant ndNis permit.
AIR HANDLING UNIT (OVER 10.000 CPM)
.'ig,mmre ofA ream /Co moo Dote
EXHAUST HOOD(W/DUCT)
PAID
HEATING UNIT (TO 101),000 BTU)
H RUOUS MATERIAIS DISCLOSURE
Dare Receipt It
Will the applicant or i.e.. building occupant store or handle haamdous material
as delis d by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety
HEATING UNIT (OVER Mj)000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
Cade, Section 25532(e)?
❑ Yes 11 No
BOILER - COMP (3HPOR IW,00t10'I'U)
NUANCE DATE
aY
Will the a lianmrfmurc building occupant use i mrdeviroe which onto
Pp gob P
BOILER - COMP(OVER JO ,"B'MP,
Area
Di'mi sus air contaminants m Defined by the Boy Aree Air Quality Management
1 Uissrim?
D
�Ity�
1 ❑ Yes ❑ No
I have read Incautious the In utious materials requitements under Chapter 695 of the
•VOY
ate
/s 99
NEW RESIDRN'1'IAL MECIL SQ. FT.
California Health & Safety C ode, Sections 25505, 25533 nod 25534. 1 understand that
if the building does not cummmly have a ¢nuns, that It is my responsibility to runty the
mcupam of the requirements which must he met prior to issuance of a Certificate of
% u
i V fJf �n
Occupancy.
ISSUED BY:
Owneroramhoried agent Dote
- 'fOIAL:
of -rlct