27631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESION - PERMIT No.
APPLICATION/PERMIT PLUMBING-MECHANICAL `
BUILDING ADDRESS.
DIVISION BUILDING PROJECT IDENTIFICATION 27631
BUILDING/A�DDREgS: SANITARY NO. APPLICATIONSUBMITTALDATE
•L/ J/ '�Y� UNIT LOT
OWNAMEKK//JJ PHONE: ONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
. A ECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: pxoNE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE ,BrLDDG/ .ELECT PLUMB MECH
L� ❑ ❑ ❑
LICENSED CONTRACTORS' DnsoCha terg APPLIANCES-RESIDENTIAL
qy�z thereby affirvision 3 ofthneedunderpmvisionsMC Code
9nd mmecense iN JOB DESCRIPTION
�i100 Section 7000)of Division 3 of the Rosiness and Professions Code,and my license is in pAbIET S
W full force anJ Vie/�� 2/ UPT02WAMPS
Q U Livens ms`�Lic.# /
tiW
a Date Convector '''',,,�....vvv�""""
I"'y 3 ARCHITECTS ,ARATION Q, 201-1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
ZOvs I" / OVER VOTE AMPS
O Z�p 1 understand my plans shall be used as public recgrds. '
F rn Fc.W] SIGNS ELECTRICAL
Q y,z,....II L¢ensetl Professonel
�'fY moma OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/INISC.
3 L F I hereby affirm that I atm exempt from The Contractor's License Law for the
O fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
which requires a permit to construct,alter,improve,demolish,ar repair any swcturc
Pmiorm its issuance,also requires the applicant forsuch pttmitto file asignedstmern POWER DEVICES
R��O that he is licensed pursuant to the provisions of the Contracmrs License Law(Chapter
p�+ 9(commencing with Section 90OF of Division 3 of the Business and Professions Code) SWIMMRIG POOL ELECTRIC VALUATION
µ'] or that he is exempt mandown it the basis far theelleged exemption.Anyviolamww
[-. 6
Section 7031.5 by any applicant fora permit subjects the applicant m a civil penalty of OUTLETS-SWITCHES-FIXTURES /f�/
^�- O not more than five hundred dollars($500). (/(/
K ❑ l,esownerofthe property,ormyemployeeswith wegesestheirsolecompensetlon, NEW RESIDENTIAL ELECTR _SQ.FT. TORIES TYPE CONSTRUCTION
pW, will do the work,and Thcannoture isnot intendedomffered fmsule(Sea.]044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who law Ids or improves thereon,end who does such work himsel f or through his
ownemployces,provided That such improvements are notinrsnded oroffered forage,If. OCC,GROUP RES,UNITS
however,the building orimprcvemem is sold withinoneyearofcompletion,Rainwater. TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as ownerofthepropeny,amexclusively contracting with licensed conlracmn to QTY. PLUMBING PERMIT FEE FLOOD ZONEAPN
construct the project(Sec.7W,Business and Professions Code:)The Cannacm/s
License Law does not apply m an owner ofpmpery who builds or improves Thrown,and PERMIT ISSUANCE
who contracts forsuch projects with membrirnor(s)licensed pursuaonotMContracmr's
License Law. ALTER-DRAIN&VENT-WA ) FEE SUMMARY
❑ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DECE UTSIDE
SANITARY Y_N
Owner Dara• DRAINS-FLOOR,ROOF REA,COND. RECEIPT#WORKMAN COMPENSATION DECLARATION SCHOOL TAXalrfYN
eCompenrmion that lhave
rance .rawi esiof cupenTmof(Saasurc.oreee C.)whi of FIXTURES-PER TRA RECEIPT#
cover'al Compensation wrdasumnce r certified copy thereof(Sec.3800 Leb C.)which KME Y N
covers all employees under this ou6mir./�x/7053 GAS.EA.SYSTE 11 .40UTLETS RECEIPT#
Policy# a ,,GG��//N VV BUILDING DIVISION FEES
Company �I GAS-EA.SYS -0V R4(EA) PLANCHEC E
ElCertified copy is hereby fumiehed.
❑ Certified copy ie filed with the city inspection tlivision. GREASEAN STRLWASTEINTEI6CE GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE AP SOILS FEE
COMPENSATION INSURANCE
ur les Md.seelionneed motbe completed ifthepmnit is forone hundraddollars($100) SEWE -SANITARY-STORM EA.2 ENERGY E
s.
I certify that in the perfomunce of the work for which This permit is issued,l shall WA HEATER W/VE E
not employ any pemon in any manner so as To become subject to the Workers' PAID
Z Compensation Lewsof Celifamm. Date WA RSYSTEM/I'REATI Data Receipt#
Applicant
�y NOTICE TO APPLICANT:If,after making this Cenificata of Exemption,you should NEW IDENTIAL FLMB. SQ. TOTAL:
E-' ti become subject to The Worker's Compensation provisions of The Labor Code,you must
forthwith comply with such factitious or this permit shall be,deemed revoked. RUH ING FEE
Z
CONSTRUCTION LENDING AGENCY S MIC FEE
1 hereby affirm that there is a construction lending agency for the perfmmence of
U O the work far which this permit is issued(Sec.309],Civ.C.) TOTAL: LECIRIC FEE
Its fender's Name
O Lender's Address QTY. MECHANICAL PER T pEg PLUMBING FEE
U I certify That T have reed this application and stele that the above information is
comet.l agree m comply with all city and county ordinances and that,laws relating to PERMIT ISSUANCE MECHANICAL FEE
tn building construction,and hereby salmon representatives ofthis citymenterup`n We
U z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree To sate,indemnify and keep hafmless the City of Cupertino against
liabilities,judgmems.costsandexpenees which may in any way accrue agaimtsald City AIR HANDLING UNIT(TO 10,000 CFM)
cmase spume,of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicant/Contractor Dam EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) DateReceipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) OTAL:
Cada,Section 25532(e)4
❑ /�
Yes g� VENTILATION FAN(SINGLE RBSID)
BOILER-COMP QHP OR 100,000 BTU) ISSUANC ATE
Will Theapplicantorfuturebuild ingoccu ruse equipmentordevicee which emit ppyy p
hazardous air comaminants as define the Bay Area Air Quality Menegemem BOILER-COMP(OVER 100,000 BTU) P�A 1 0
District?
.l` 11 Yet o NEW RESIDENTIAL MECH.-SQ.PT. �tl/nf n
I have read the hazardous materials requirements under Chapter 6.95 of the ��
Calif
1th&Safety Code,Serio 5505,25533 and 25534.1 ondersmnd Thai RI�1I
fifthdoesnote ,n0yhv T ant,that iT is ibility to notifyThe 4��Yuvea <eca uir erns m t eT prior t m ceo(aC mUur,oveOwnerrauthorized age at Dam TOTAL: ISSUED BY: