27653 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27653
V �s' BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: JO�po AJ„ SANITARY NO. APPWCATION SUBMITTAL DATE
PAq&�Pdicl (7A VV� UNIT# LOT# 1� 7
OWNERS NAME: PHONE: CONTRACBDR'S NAME: 1 LIC NO: ..JJ
N/C CONTROL#
•ARCHITE IENGINP.ER� LIC NO: ADDRESS:
ON D
CONTACT: G�It / r _C PHONE: �p`(��) p QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
B'� Lf�/ 7 dpfp BLDG ELECT PLUMB MECH
PERMIT Issu,wce fGv � El 11
LI NSEDCONTRnderpmSDECLARATION APPLIANCES-RESIDENTIAL q , ,OB�e�olvn
yhz Thereby affitmthml E!IDOCnsed undo OR'SslonsofChaprer9(oommencingwiN !/ it CRI
00 Section 7000)of Division 3 of Ne Business and Professions Code,and my license is in PANELS
cv, fullforce and aIle 1. Up TO 200 AMPS
License Class _ J Lic.# �fY0'-" #--
rFia6y Date Contmc�. $OMS 201.10(g PS
z FO N Zy
ARCHITECTS DECLARATION OVER 1000 SQ.IT FLOOR AREA $/SQ.Ff.
Q I understand my plans shall be used as public records.
r41t Licensed Professional SIGNSELE C
hhOWNER-BUILDER DECLARATION SPECIAL CIR BC
iqs��d0p'U I hereby affirm that em exempt from the Contractor's License Law for the
u13 W m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP,MIETER OR POLE TNST.
IS OO; which requires a permit to construct,alter,improve,demolish,or repair any structure
2}E priorto its issuance,also requires the applicant forauch perrnittofile asigned statement POWER DEVICES
Gp that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W-„m or that he is exempt therefrom and the basis for no alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of I/V
O
nof more than five hundred dollar($500).
W ❑ I,asownerofthepmp M,ormyemployeeswiNwagesmtheirsolecompensadm, NEW RESIDENTIAL ELECTR S Q'FT.
STORIES TYPECONSTRUCfION
a will dothework,and the structure isnot intended oroffered forsale(See.7041,Business
and Professions Coes:The Contractors License Law does not apply to an owner of ,
propertywhobuildsorimproves thereon,and who does such workhimsclforthroughhie OCC GROUP RES.UNITS
weemployces,providedthat such improvemcntsare not intended mothered forage.If,
however,the building crimprovement is sold within one yearofcompletion,meowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepropeny,amexclusivelyconuamingwithliansMcomrectorero QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7644,Business and Professions Code:)The Contractor's
License Lawdoesnotapply man oererofpropeny,whobudds orimprovesthereon,and PERMIT ISSUANCE
whocontmas forsuch projects with acommemand licensed pursuant to the Contractor's ALTER (EA)
License Law. FEE SUMMARY
❑ Tam exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Data DRAINS-FLOORROOFAREA, RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ I hereby affirm that I have a certificate ofer senrto self-insum,or a certificate of FlXTURES-PER TRAP RECEIPT#
Workers'Compensation Insurance or a certified copy hereof(Sec.3800,Lab C.)which PARK FEE Y N
cove"
all employ u der this perm�f GAS-G.SYSTEM-1 INC. tITLET RECEIPT#
Policy#—_ BUILDING DIVISION FEES
Company 1 n 3 �I {,{' $A'.+1((�A GAS-FA.SYSTEM-OV 4( A) PLANCHECK FEE
I@ Cer ified copy is hereby fumished. g111 qS
❑ Certified copy is filed with the city inspection division. 9 GREASE/INDUSTRLW TIL CE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G P
SOILS FEE
COMPENSATION INSURANCE
(This section need nt becompleted ifNepemhit is for one hundred collets($1110) S WER-SANITARY-STORM EA.200PT. ENERGY HE
or leas.)
I certify that in the performance of the work for which this permit is issued.I shall ATER HEATER WNP.NTM ECTR
not employ any person in any meaner ao as to became subject to the Wmkera' PAID
Compensationlawsof California. Date WATER SYSTEM/IREATING Pate Receipr#
Q z Applicant
z C NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NE RESIDENTIALPLMB. SQ.ET. T TAL:
C-' rA became subject to the Workers Compensation provisions ofthe Labor Cade,you must
forthwith comply with such provisions or this pemtit shall he deemed revoked. BUILDING FEE
G
PW (,] CONSTRUCTION LENDING AGENCY SEISMIC FEE
, z I hereby affirm that there is a construction lending agency for the pertarmence of �. + TAL: ELECTRIC FEE
O the work for which this Fermir is issued(Sec.3097,Civ.CJ
C) r... Lender's Name PLUMBING FEE
FU+ Lender's Address MECHANICAL PERMIT FEE
1 certify that T have read this application and state that rhe above information is
>" L1a cortem.I agree to comply with all city end county ordinances and stem laws relating tip PERMITISSUANCE MECHANICAL FEE
L') buildingeoustruction,and hereby andante representafivesafthis city to enterupon the CONSTRUCTION TAX
V y above-mentioned property for inspection impasses. ALTER OR ADD TO M
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs milexpemeswhich may in anyway accomagainst said City AI IT(TO 10NO CFMI
incouse fthegrantlngof Nispeyn t. FIR HANDLING UNIT(OV FM
quenCeo i
Signaturecool'Appl�icentt//Conrraclnr Qe.- J "Dee%S EXHAUST HOOD(W/DU PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(10 l U) Date Recap[#
Will tbeur Ciaut or ertion ture Mundial ng Code,occupant
pmr9store 2,handle He.11ousmmedal BEATING UNIT(OVER 100,000 BT OT
as define)by the Cupertino Municipal Cade,Chep¢[9.12,anJ the Health and Safety
Code,Section 25532(e)7
❑Yes ❑No VENTILATION FAN(SMGLE RESID)
Will the applicant or building occupant useequipment nrdevices which emit
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
'hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,01s)BTU)
Disoimi
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ,FT. p�
1 have mad the hazardous materials requirements under Chapter 6.95 of the 1_
CeliPomin Health&Safety Code,Sections 25505,25533 end 25534I understand than
if the building does not currently have a hand,ena ,that it is my responsibility to notify the
occupant of the requlremems which mus[be no prior to issuance of I Certificros of N 25 #—
Occupancy. y
Owner or amborim gem Dat TOTAL: ISSUED BY:
OFFIC