27916 Pis—
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING- d. RI AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27916
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. AFFUCATIONSUBMRfA.LLDATE
UNIT# LOT#
-75
OWNERS NAME: NE: CONTRACTOR'S NAME: LIC NO: J
SAC CO OL0
SOUTHLAND C
CHITECT/ENGINEER: LIC NO: ADDRESS: _ ❑
CONTACT: PHONE: .23_P_ESTANA -I -F-
Q ELECTRIC PERMIT PEE BUILDING PERMIT INFO
PAUL Sarrett 510 463 2711 ELE PLUMB MECII
PERMIT ISSUANCE 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOBIOESCRIPTION
MWz Iherebyaffimn Na l am livenaedunderp.visioncofC'bum!)(emormacing with
woo Section 700duf Division 3 afthe Businessand Profnsi...Code,and my license is in PANELS Install.
q� fall force and effca. n Park i[y-,
FZ License Clayyrq _A p� IV IIP 70200 AMPS y
y Q r4 Dov—V 1 Contractor. @-�y.q 301-10011 AMPS 'Int liahts
ZSNZ� — -....,�, TECTS DF.CI:ARAi'VtAI'en OVER IOOOAMPS
SQ.FT.FL OR AREA S/SQ.FT.
OZ—Q l understand my plans shall b,used as public records.
SIGNS ELECTRICAL
: ,, Licensed Pmlessioned
W I OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. rI
xO I_ 1 hereby affirm that I am exempt from te hContractors License Law for the OCT 31 1995 <-
W3ay following motion,(Section 7031.5.Business and Profession Code:Any city or county TEMP.METER OR POLE INST.
I=LL Ooe; which rcqubes a permit to construct,alcor,improve,demolish,or repair tiny structure
C a7 priorto its issuance.also requires the applicant fm such permit to file a signed statement POWER DEVICES GIIr �1'
yl DO that he is licensed pursuant to the provision of the Contractors License Law(Chapter l+ LUr�I'{ 1 rn
L o�' 9(commencing with Section 7(X10)of Division 3 of Ne Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is nempnherefrm andlan basis for the dlegedexentpsion.Any violmionof OUTLETS-SWITCHES-FIXTURES so -
hZQ Section 7031.5 by tiny supplicant for a permit subjects the applicannaocivil pemlty of
z not mart than five hundred dollars(55110). NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
❑ omewrk,mahcpropccty,orntyemparaindonflwageanthe(SesI ompensn...a
q will dothewons and e:no ontuanranotinvnance, ofw does not apply
to an owner
of
and propProerty
who
Cade:The ves tars s nd who Lew does or,apply to an owner of
own ertywhoes,prolds vided
Oat aatherton,andwhodmasuchwmkhrofferedthraugbhis '
cmployeca,pingor improvement iss sold
within ne esomf amplemr.theafortaa r- OCC.GROUP RES.UNITS
howeer willT. b own the
en fproving than
hedidnod buildo improve for the ase of �•
bee.). will have the buNen of proving 1Mt he aid fat build or improve for purpose of
ate.).
❑ I,aaowmronne.romrty,.mnemaively Convnedng win nanaea Convannrsm QTY. PLUMBINGPERMIT PGE FLOOD ZONE pPN
onvuct the project(See.7044,Business and Professions Coar.)'Phe Contracmr's
License Law does not apply to anownerofyroand,whobuildsor improvesthemon,and PERMIT ISSUANCE
who convects formch prjects with acanwctor(e)licensed pmmannothe Contractors ALTER EA
License Law. HEA) TTG SUMMARY
❑ 1 um exempt unJcr Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE UTSID .FS
SANITARY Y N
Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,ARCA,COND. SCHOOLTAX Y_N
I herebyuffirm that i have a certificate ofconscnno self-insure,or a certificate of FlXTURCS-PER TRAY RECEIPT
orkers'Compensation Insurance maceration copy thercof(Sm.3900,Lab C.)which PARK FEE Y N
covers ell emalpvei• .i,, GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
F Policy L'13-10BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHBCK FEE
❑ Certified copy is hereby famished I.
❑ Certified copy is filed with the city inspection division. REASFANDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G SETRAP SOILS FEE
COMPENSATION.RaSURANCE
(This section need not be completed ifthe Permit is foram dollars(EIW) SEWE -SANITARY-STORM EA.20017. ENERGY FEE
or Icss.)
I cattily that in the Performance"dre work ichunti permit is issued,l shall WATE IFATER WIVENT/ELECIt
not employ any person in any m eta become aubje to the Workers PAID
Compensation Laws of California. Doers WATER YSTEM?REATING Data Receipt#
Z Applicant AN 4
20 NOTICETOAPPLICANT:ILefu ing this Ccrdfi . ration.you should
WR DGN'HAL PLMB. SQ.Fi. TOTAL:
V) become subjet to the Workers Cc mati o e Lmnr Code,yyyQQplyykmust
forthwithcomplywahmehpmv'm or hs r till be
deem ' BUILDING FEE
0. Q CONS ENDING AG QTS SEISMIC FEE
Z I hereby affirm thatthe isato than lensing c firths#errant, of
O the work for which this perm is issue ec.3097,Civ. J TOTAL: ELECTRIC FEE
t...s Lender's Name
0O OF Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
IJa I certify Out I have ad this application and sate that t ave information is MECHANICAL FEE
contact.I agree.comply ith all city and county odinat end start lows relating. PERMIT ISSUANCE
building contusion,end erebyauthorivereprescn a cfthis city to enter.,nine CONSTRUCTION TAX
Ll z above-mentioned progeny inspection pu ALTER OR ADD TO MECH.
(We)agree to save,in ap bmmleas the City of Cupertino against
liana it Ima casts and expenses which may in any wayaccrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
egranting fthis mrmit.
/611 -7X AIR HANDLING UNIT(OVER 00."CFM)
Si afa7`91
1Appbcan for ate EXHAUST HOOD(W/DUCq
PAID
A RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,fM10 BTU) Data Receipt Jr
will be...[at r future building occupant atom or handle hauNous material
as defined by the Cupertino Municipal Code,Chapin HEATING UNIT(OVER 100.(#11 BTU)9.12,and the Health and Safety TOTAL:
Coda Section 25333(.)7
El Yea ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
WilHhee licantmfuwmbuildin cu fusee tordeviceswhichemit BOILER-COMP(JHP OR IW,000 BTU)
pp Bac pan qea Air
dnus air camamiuents n de0ned by the Bey Arca Air Quality Management
BOILER-COMP(OVER 100,000 BTU)
Vlcl'!
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
I have read the hamrdous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if the building don not currently have amount,that it is my responsibility.notify the
oecupom of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner m aadvailed agent Date TOTAL: ISSUED BY:
OFFICE