27685 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDTNL .. PERMIT NO,
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 27685
BUILDING PRI3JE(7 IDRNI IFICATION
BUILDING ADDRESS: ,• , 1 SANITARY NO. APPLICATION SUBMITTAL DATE
{ 2 G W `I UNIT# LOT# 1^2G r1
O AMP H �t0--" NPy CONTRA RS kYA-MFr/1`� LIC NO:
-�J/LVs/x//11 `��•`+iasGr,4gL N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: e -
QTY. „ ELE-CIRIC PERMIT FEE BUILDING PERMIT INFO
w ,,%1 � BLDG ELECT PLUMB MECH
PERMIT ISSUANCE EJ
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL IDB DCSCuu IPTO
naZ Ihereby affirm Division 3.licenausindeT ssand isiomimcs Code,
with � klw�w/1
00 Senior and e f Division 3 of Ne Business and Professions Cade,and my liana is in PANELS
Wl I e
5d
fullformand effect, UPT0200AMPS
6 Zu Licenx Clua Lic.N
tFi.ah Dale Contractor 201-IOW AMPS
ZOy� ARCHITECTS DECLARATION OVER IOOOAMRS SQ.FT.FLOOR AREA 5/SQ.FT.
1 understand my plans shall be used m public records.
P'yW - SIGNS ELECTRICAL
hj Licensed Professional
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUR/MISC.
o00 I hereby affirm that I sat exempt from the Contractors License Law for the
Is1' 0vFi following reason.(Section 7031.5,Business and Professions Code:Any city w county TEMP.MEIER OR POLE[NST.Ki which requires a permit to constmct laws,improve,demolish,or repair any strucwrcp e
Y� pdwmitsisa.....elsorequiosthe applicant forsuchpermit tofileasigned statement POWER DEVICES Q A n IJ Q V
G OY that he is licensedIons...I to the proviaiom of the Contractors License Law(Chepwr
aKCLL 9(cmmnencing with Section 7000)of Division 3 of Ne Businessand Professions CodO SWIMMING POOL ELECTRIC - VAL ATION
(y Ma or that he is exempt therefrom and the basis for the alleged exemption.Any vfatmon of OUTLETS-SWITCHES-FIXTURES '�
< Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
S �ohan five hundred dollen(5500). NEW RESIDENTIAL ELECfR g Ff„
oho wmeroflhepmmry,ormyemplayeeswith wagaastheiraolecompcnse[ion, ST 1 TYPL+CONSTRUCfION
0,6666 didmhework,end theswmureisnotimrndW woffvcd fwxle(Sa.]049,Busirresv
d Professions Code:Lre Camractors License Law does not apply to an owner of
pmpertywhobuildsorimprovesthercon,andwhodmssuchwoAhi xlford ughhis OCC.GROUP RFS.UNITS
ownemployma.providedNat such improvements arenotintendcdoroffemdforsale.If,
however,the buildingor improvement is sold within aneyearof completion,the owner- TOTAL:
builder will have the burden of proving Net he did not build or improve for purpose of
s❑)I,asownerofthepmMny.umexclusivelycanvactingwiNlicev .ntnetwsm QTY.'�tt 'PLUMBINGPERMIT FEE FLOOOZONE APN
instance,the project(Sec.7Oa4,Business and Professions Cade:)The Cisomen T's pPRMIT ISSUANCE
License Law Aces not apply to on owner of propeny who bui Ids or ins proves thereon,and
whicimm sets forsuch prajects with.contructoroolicenaed purmant tothe Contractors ALTER DRAIN&VfJ9T WATER(EA) FEESUMMARY
License law.
❑ l am exempt under Sec. ,B&P C for this reeaonOUTSIFEE
D
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner -D..- DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm that d have a certificate ofconsentto self-insure,or a cenificaui of RECEirr#
FIXTURES-PER TRAP
'
Workers'Compenxtion Insurance oracertified copy thercof(Sec.3800.Last C.)which PARK FEE RECEIPTp-N
-
covers all employee'.under this permit GAS-EA.SYSTEM-I INC.4 OUT-ET3 'Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANC14ECK FEE
❑ Certified copy is hereby famished.
❑ C<nifiedcopy is filW with Ne city inryection division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMP11ON FROM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(Thissneduri sed not be completed ifthe permit is for one hundred dollars(5100) SEWER-SANITARY-STORM EA.201 ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VIIJELECTII
not employ any person in any manner an ss w become subject to the Workeri PAID
Compenaationlawsof Califamia. Data WATER SYSTEM/IRRATING Dote Receipt#
Z APPlicant
NOTICE TO APPLICANT:If,after making this Cenifiate of Rxmption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) become subject to the Workers Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions or this permit shall be domed invoked. BUILDING TEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the performance of
U O Ner
e work for which this permit is issued(S .3097,Civ.Cd ELECTRIC FEE
p
Lenders Name
I` 0 Lender's Address QTY., MECHANICAL PERMIT FBE PLUMBING FEE
U d certify that I have rad this application and suite Net the above informNom is MECHANICAL FF.P.
correct.l agrees to comply with ad city and county ordimness and slate laws relating to PERMIT ISSUANCE
building construction,and hereby authorize repmsemativesof Nis city to enter upon the CONSTRUCIIONTAX
U .bove-meat once property for inspeemon purpose.. ALTER OR ADD TO MECH.
(We).gree to save,indemnify fond kap harmless the Ci��UIppYYY'ef Purim a 'net
liabilities,judgments,comsandexpenass which may in any waypepa AIR HANDLING UNIT(TO 10,000 CFM)
comaquenec of the granting of thia pmem.
AIR HANDLING UNIT(OVER 10,(100 CFM)
S' a rt f Applicant/Conoacmr Dam EXHAUST HOOD(W/DUC1) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO Iffl."BTU) Date ' Receipt#
Itheapplicam orfuture huitding occupant score or hurtle hezallom material HEATING UNIT(OVER IW,(Xp BTU)
TOT L:
u defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section Vic. a)T VENTILATION PAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP(3HP OR UNBOOD BTU) ISSUANCE DATE
Will the applicantor furore building wcupdnt useequipmemardeviceawhiehemit p
hamrdaus air conumin acts as defined by the Bey Arm Ab Quality Management BOILER-COMP(OVER 100,000 BTU) �Io 4
�Disvicl7 'r
❑Yes 0 N NEW RESIDENTIAL MECH. SQ.FT. 9
I have read the hazardous mmemd,requiremems under Chapter 6.95 of the y���-� a6�j/1
California Health&Safety Code.Sections 25505,25533 and 25534.I understand Net H s7
iTthe building encs nm currently have a tenant that it is my responsibility to nmify the �'(/�..
rRcupam of she requirements which must bo met prior to issuance of a Certificate of Cyd/
Occupancy.
Owner or euthoriz agent Date TOTAL: ISSUED BY:
OFFICE