27014 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OFCUPEPLUMBING-MECHANICAL - PERMIT NO. 0
BUILDING DIVISION
slory APPLICATION/PERMIT
BUILDING PROJECT IDENTIFICATION
14
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
d�P�'� 1 1.�R/✓�R.. �j,�/I UNIT LOT# C1 —�,� ['
OW/NE,RSlNAME: p' - �fp-H-Of�N/E: C�NTRpCTOR'SrNAME: �'`'. LI/C-NO: 0 1 J
f (C L [ /7 '�II3 - � D yL/PI. f(� /OS N� CONTROLp
ARCtIITELT/E GINEBR: LIC NO: ADDRESS: ❑ ,
coNTAcc PHONE: BUILDING PERMIT INFO
l,b� >-x QTY ELECTRIC PERMIT FEE
BLDG ELECT P U MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION gPPL1ANCE5-RESIDENTIAL
camz Ihereby affirm that famlicensed undmprovlslons of Chapter9(commencing with OB DESCRIPTION
�CO Section 9WO)of Division 3 of the Business and Professions Code,and my license is in j20 -
ELS
4 V full force and effect. ,
z License Class - Lic.# 02WAMPS
Nay Date Contractor.
Hudid AMPSz-aARCHITECTS DECLARATION R IMOD AMPS SQ.FT.MOORAR Apm�C1 Iunderstandmyplanashallbeusederepublicrecords. d/SQ.FT.
NS ELECTRICAL
ProfesemnalOWNER-BUILDERDEcCopmaION CIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Convectors License Law for the
340 mfollowing mason,(Section 7031,5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
Vl wa J which requires a permit In consom",alcor,improve,demolish,or repair any structure
wad Prior m its icimume,els curares the applicant for such permit to file a signed statement POWER DEVICES
O pC for he is licensed pursuant o the provisions of the Contractor's License Law(Chapter — 1 '
co 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
-„y or that he is exempt therefromand the basis for the alleged exemption.Any violation of
Y Section703 LS by any applicantfmapermit subjects the applicant macivil penalty of OUTLETS-SWITCHES-FIXTURES
Qnot more Nan five hundred dollars($50%
W m ❑ I,asawnmopheproperty.ormyemploymewith wagesastheirsolecomperuetion, NEWRESIDENTIALELECIR STORIES TYPE CONSTRUCTION
4 wiildo the work,and the emcmmis nolitemndedmifimod forsale(Sec.70G4;Business t
and Professions Code:The Conusctm''s License Law does nm apply m am owner of
Property who builds m improves timmon,and who does such work himself or through his
ownemployees,provided that such impmvementsam not intendedorofferedforsale.If, OCC GROUP RES.UNITS
however,the building m improvement is sold within one year of completion,the awmer-
builder will have the burden of proving that he did not build m improve for purpose of TOTAL:
sale.).
❑ Lasowneroftheproperty,smexclusively contracting with licensed contractors to QTYPLUMBING PERMIT FEE FLOOD ZONE APN
mnstrum the project(Sec,7(144,Business and Professions Code:)The Contractor's
License Law doesnm apply manownerofpmpeny whabuildsmimproves thereon,andPERMIT ISSUANCE
who contracts fmsuch projects with armarmctm(s)licensecipursuamt tothe Contractor's
License Law, - ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
13I em exempt under Su. B&P C for this reason
BACK FLOW O SID PS
PROTECT.DEV ICF.
OwnerDare SANITARY Y
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
EII hereby affirm that l base a onnificam mlcomsent to self-insure,ore ceNRcaI of SCHOOL TAX Y_N
Workers'Compensation immirmce ora certified copythereof("e.3800,Lab CJ which FIXTURES-PER TRAP RECEIPTp
covers all employee's under this Permit. PARK FEE Y N
oil
Policy# GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Company BUILDING DIVISION FEES
❑ Certified copy is herebyfamished, GAS;EA,SYSTEM-OVER 4(EA)
❑ Cmified cO PLANCHECK FEE
Py is fled with the city inspection division. -,y,0'�" GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
-n+^,
CERTIFICATE
COMPENSATIO rIN URANCE ON MOM W ORKERS' Appppp [G AS" SOILS FEE
(This action need not be completed iftbe permi[isf Rltn p�ol $Ill, �.- SBWE�(,aSA i RY-STORM EA.20010', ENERGY FEE
or less)
I certify that in the Performance ofthe work forwhicpennitisislu d;lshWl:r W ECTR
not employ any person to any manner so as to becom bjat with)wO k
Compensation Lawsof California. Dam- % �- r u� PAID
Oz Applicant —�Q d S MIDI - NO L. Daro Rweipt#
C NOTICE TO APPLICANT:If,after making this Certificate ofEy�gti ;.you sit ESIDENTIAL PLMB. SQ.PT,
(~ V) become subject ork
o the Wers Compensation provisions Of the L$tl l L�o�e, normal TOTAL:
forthwith comply with such provisions or this permit Ri s Ibedeemed revoked:41
BUILDING FEE
[Ta A CONSTRUCTION LENDING AGENCY .a" ' SEISMIC FEE
z I hereby affirm that there is a construction lending ageney'fortbe performance of
V Q the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
Lender's Name 4
ULender'a Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LkI I certify that 1 have read this application and sham that the above information is
'nett.Iagree to comply with all cit and court Ord'
Qr PY Y county mantes and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
pJ building construction,and hereby authorize represemldims of this city to enter upon the
V 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH, CONSTRUCTION TAX
C (We)agree to save,indemnify an a harmless Ne Ciry of Cupertino against
liahilities,judgme I rots and exp hmey in any wayacerue against said City AIR HANDLING UNIT(TO IO,000CFM)
i copse u oft granting sw n
e AIR HANDLING UNIT(0 IO,IXq CFM)'
Sig mreofpppli:ant/Cont G6 T Date•J EXHAUST HOOD(W/DUCT) l
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicant m future building occupant store or handle haardous materiel
os defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(a)P
11 Y. 11 No VENTILATION FAN(SINGLE RESID)
Will the applicantorfummbuildingoccup ruseequipmentmdevimswhichemit BOILER-COMP(3HP OR 100,(100 BTU) _ ISSUANCE DATE -
hazardous air contnminanls as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0011 BTU) PA
I,
am
Y ❑Yes ❑No NEW RESIDENTIAL MECH, SQ.PT.
1 have read the hazardous materials requirements under Chapter 6.95 of the APR
Colifomle Health&Safety Cook.Sections 25505,25533 and 25534.1 understand N199�i
at 1 9
if the building does not currently have a tenant,that it is my responsibility m notify the CSI y
occupant of Ne requirements which must he met prior to issuance of a Certificate of Uf L'L'
Occupancy.
Owner m amhonzed agent Date
TOTAL: ISSUED
OFFICE