27694 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ILDI •. .-1 V 1 A PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27694UILUING ADDRESS:
IIUILOING PROjFCT IDFWIf'ICA'L'ION
O
SANITARY NO. APPLICAUUNSUBMITTALDATE
®L-T6 O UNIT M LOT g
OWNERSNAME: PHONE: CONTRACI'O LIC NO: at"' Y
�41 (•sr� N/C CONTROL M/1
Cf11TIiCTp?NGINF:I?R: LIC NO: ADD .SS: U`� ^1I�J�,�Jy�'y'.
CONTACT:` PHONE ❑ _
9 QTY. ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
r ' 1 � 47Vh PERMIT ISSUANCE ELE B MEC B PLU
I
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-RESIDEMIAL
tYZ I hembyaffinn thallam licensed underprovisions ofanpter 9(commencing with JOB DFSC ON
00 Sadon 000E of Division 3 Office Business and Professions Cedefull force and affect. ,and my license is in PANELS
<z wwuUyl License Class Lic.Y UPT02W pMPg
yG=y Date Contractor 201
Z OO`tt— ARCHITECTS pFCLARATION SQ.FT.FLOOR AREA
I understand my plans shall be merest pahlic recoNOVER 10(10 AMPS
s. $�Q'FT'
ELEC
4 ,�F„-I Ltceved pmfesnonal SPECT LCIR ULT/
aJ E< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
3OaU 1 hereby affirm that 1 am exempt from the Convector's License law for the
0vf—j which icgmresa amdnn amal..1,Businessimprove,
de oli Cone:Any t
which requires u permit m conavuct,alto,,improve,demolish,or re y n y or county TEMP.METER OR PoLF.INST.
pair any structure —
summers
Yu'C) prionnimissuance,cam,ed pralso
nt to th the
Prvisionscant for thsuch ConarNovato Lifile nse La smumat POWER DEVICES
y Y0O that heis licensedpSectio too Provisions Of the Conwcurs License Law(Chapter'4'Xp�' or me,
heisexemlthumbra OWB).f SOL'ormalle Business and Professions Code) SWIMMING POOL ELECTRIC VA AT
ul—w orthoheisex byt y.ppEmand Ne buisforthectsthe exemption. civilppaRyof "a�a
ZQ
Section than
vin hundred
doll rs( pcmrit subjects the applicant to.civil pcvhy of OUTLETS.SWITCHES-FIXTURES
G not marc than fiv.hunrred dollars($500)
o ❑ 1,usOwnerofNeproperty,ormyemployeeswithwegesaztheirsolecamPerot n, NEW RESIDENTIAL ELECIR _S .FT,
STORIES TYPE CONSTRUCTION
0.,340 willdo the work,andtheswcturc is not immadedoroffered forslk,(Sec.9(144 .Buns"
and Professions Code:The Communes License Law dors not apply to an owner of I O
pmp ywhobuildsorimpmveathereon,andwhodocesuchwork himulfor Orroughhis
nemployea,pmvidedthatsuchimprovcraontsamnotimendedoroffemdforxle.If, (KCGROUP RES.UNITS
however,the building or improvement is sold within oneyenof completion,the owner OCC.
build.,will have the burdenofpmvieg that he did rut build.,improve for purposs of DEC
sale.). �!
❑ I,osowneroftheprop.ny,nnexclusivelycontremingwithlicensedcontrectorsm QTY' UMBING PERMIT FEE FLOOD ZONE AN
QA
ro armact the project(SIL.0044,Business and Prof actions Cade:)The Convectors CITY
License Luwdaa ne
not apply man owrofpmNay who builds or improves thereon,and -RMIT ISSUANCE V (a f'tH��ltlO
who com mets for such pmjats with a con tractogs)licensed pursuant lothe Contractor's
Liana Law. ALTER-DRAIN&VENT-WA (FA) FEE SUMMARY
❑. 1 um exempt under Sec. ,B&P C for this reason
BACK FLO ROTECT.DEVICE .ID
Owrmr Date SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS- OOF,AREA.CO RECF.IPTN
I hereby am.Natlheve s<ertificnm of conxnno sslf-ivum, SCHOOL TAX Y N_
aracce"Emam of FIXTU - ERTRAP RECEIPTg
odem'Compemation lnau'ance oracrnifiW copy th<rwf(See.3800,Lab C.)whi PARK FEE Y N
ycovers all employee's under this p.rmit GA - ,SYSTEM-1 INC.40 TS EII4k
Policy p
Company BUILD DI SI FS
❑ Cenified copy ie hereby furnish W. S EA.SYSTEM-OV 4( A) PLAN CHIiCK FEF,
❑ Cenified copy is filed with Ne city inspection division. REASNINDU INTERC R
GRAD W G FEE
CERTIFICATEOMPE EXEMPTSATIONIONFRAN WORKERS' ,A TR SOILS FEF.
COMPENSATION INSURANCE
(This section mad not be completed ifthe permit is for one hundred cladim($1 SEWER NI Y-STORMM.2 FT. ENERGY FEE
—�
I ttnify that in the performwtt of the work fm which this pemtitu issued,lshall WATER HEATER W/VENT/ELI
Lk
not employ any person in nay manna'so as to become subject to the workers' PAID
Z Compensationlawsnf Culifomia. Data ATER SYSTEM/TREATING
Applicant -
Data
> NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW orSIDENTIALPLMB. SQ.FT. O
7 r become subject to the Workers Compensation Provisions of the Labor Cede,you must TAL:
Uforthwith comply with such Provisions or this permit shell be deemed invoked. BUILDI E
L. Q CONSTRUCTION LENDING AGENCY SEIS C B
Z 1 hereby affirm that then is a construction lending agency for the performance of
O thewnrk for which this permit iv issued(Sec.31197,Civ.C.) E FEE
ULender's Name
Lander.Address QTY, MECHANICAL PERMIT FEE E
r W I certify that I have read this application and state that the above information is
0. correct.Ingrain to comply with all city and county ordinances and state laws mining to PERMIT ISSUANCE I LFEE
to buRdingeonstmction,and hereby authorize mimacn[atives ofthis city tocaterupon the
Z above-mentioned pmpeny for inspection purp.xs. AL'T'ER OR ADD TO MECII. CONSTRUCT' N TAX
(We)agree to save,indemnify and kap hamiless the City of CupmBno against
Iiabilitiea,judgmcros,costsnnd expenses whichmay inanyway accrue against said City AIR HANDLING UNIT(TO I0,000CFID
in consequence of the grunting of this permit.
-)'o
)_ AIR HANDLING UNIT(OVER 10,000 CFM)
Signatumo Appl Contmctor 1Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO UX,"BTU) Dam Receipt as
Will the applicant or futom building acupent sure or handle hazardous mated.]
as defined by the Cupertino Municipal Code,Chapter 9.12,anti the Health end Safety HEATING UNIT(OVER IM."BTU) TOTAL:
Code,Section 255320)?
El Yea 0 N VENTILATION FAN(SINGLE RESID)
WisltheaPPr=:prmutumbuildiogaupam useequipmenmrdevicawhich emit
BOILER-COMP(3HPOR 100,01JOBTU)
no soconrta IS A
as defined by the Bay Arca Au Quality Management BOILER-COMP(OVER Itio"DI'U) DEC 19 �gg�
evict?
❑Yee 11 No NEW RESIDENTIAL MECH. SQ.PT.
I have read the hvudous materials requitement under Chapter 6.95 of the CII r Ur I.UrCfiIIIVf
7C-1ifomiu Health&SaZt Code,Secti.e.25505,25533 and 25534.L understand thin Vhe building does not currently have a accent,that it is my responsibility to notify the
cupant ofthe oximmments which must he met prorm issuance ofa Cenificam of
cupancy.
wner or authorized agent Doe ISSUED B4y—, .
OFFICE