27673 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
'VSNAM
RTINO APPL[CATION/PERMIT PLUMBING-MRCHANICAI, PERMIT NO.
ION BUILDING PROJECT IDENTIFICATION 27673
ADDRESS: SANITARY/ SANITARY NO. APPLICATION SUBMITTAL DATE
(I �• UNIT# LOT#
PHONE: C RACTO 'S NAME: LICNO:_ OC NIC CONTROLp
R HI'TECT2N ELR:
LIC NO: ADDRESS: nx el # J ❑
d5
-UNTACT: PHONE: QTY J�I'-^' '
�`'I ELECTRIC PERMIT FEE BUB.DING PERMIT INFO
"a3afiGi'�,, Y'1 - BLDG ELECT PI�UM#B MECH
PERMIT ISSUANCE 0 f
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRIPTION
RoCZ I hemby grim that l am licensed under provisionsach.,un51 commencing with
on Section 7")of0ivision 3 of the Business and Professions Code,and my Homes is in PANELS
asB ll fornse d effect.,
License
rip`
GU Cl Ch ass Lic.p UP T0200 AMPS r—
y Durc Cadmium 201-1000 AMPS
ZO o, ARCHITECTS DECLARATION OVER 1000 AMPS SQ.Ff.FLOOR AREA E/SQ.FT.
OZ 0 1 understand my plans shall be used as public records.
E25� SIGNS ELECTRICAL
�d Licensed Professional
yad< OWNBR-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
X9 1- 1 hereby effort that 1 oto exempt from the Contractor's License Law for the
W 3 0.y following reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
which nyvires a permit to construct,alter,improve,demolish,or repair any structure
Y� pnorm its ivatince,also requires the epplicant for such permit to Bleasigned moment POWER DEVICES
Q O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
d WX0 T' 9(crmmencing with Section 7000)of Division 3 of the Busineaaand Pmfewiam Code) SWIMMING POOL ELECTRIC VALUATION
W—y rather heisaWarattherefmmend to basis forth.allegedeaemption.An,i,whitimuff OUTLETS-SWITCHES-Fl%'I'IIRES
(_K G Section 7031.5 by any applicant fore permit subjects be applicant m e civil penalty of
G w1 marc than five hundred dollars($5(0).
C o ❑ I,asawnerofthepmperty,ormyemployewwithwegesestheirsolewmperwtia, NEW RESIDENTIAL ELECIR —so,PT. STORIES TYPECONSTR COON
y °0 will dothewon,Codi:
The
Caisnotintendcnse Law
actW4,mminns
tined Prafessiom Cde:The Contractor's License Inw does not apply to m owner of
propeny who builds or improves thereon,end whodoes such work himself m tmaghhie
own employees,provided!that Improvement
improvements is aid mvercne intended or offered for the e.ham r.
OCC GROUP RES,UNITS
however,the building Orden of proving
issoldwithin one year ofc provefartheowner-
We.).rwill have the harden of proving that he did not build m improve fm purpose of TOTAL:
We.).
❑ hemwncrof the property,emexdusivdy commcting wiNlicrnsdconmcmrsm QTY' PLUMBING PERMIT FEE FLOOD ZONE APN
consmct the project(Sec.7W,Business end Profession Code:)The Contncbls
License Lawde.roulapply town ownerafpropenywho builds orimprovesrherern,end PERMIT ISSUANCE
whoembacts for such projects with a conmctas)licensed purstion to the Contractor's FR-DRAfN&VENT-WAT'CR +Lt
License law. pLTIRA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Nis memo BACK FLOW PROTECT.DEVICE OMSIDEFEES
SANITARY Y N
'Owner - - Bate RECEIPT#
WORKMAN COMPENSATIONDEC DRAINS-FLOOR,ROOT.AREA,GOND. SCHOOL TAX Y N_
❑ Ihercby affirm that haveocenifcme of con self-insum,aracertificete of XTURFS-PLR•TRAP RECEIPT#
Worken'Compenam inunace oro cenif py thereoI(See 3gOq 1<b C.)which PARK FEE Y N
covcnall employee's under this GA .EA.SYSTEM-I INC.40171'LPTS RECEIPTp
Policy M BUILDING DIVISION FEES
Compaay, GAS EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cerifedcopy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREAS NDUSTRL WASTE INTERCEPTOR GRADING FEE
CE TIFlCATE OF FXBMPOON FROM WORKERS' GREASE P SOILS FEE
COMPENSATION INSUgo
(Thi.,nodan cedrabpl
ecametedifthepermitisf dollan(SI00) S ER-SA ARY-STORMEA.200FT. ENERGY ME
or less.)
Icenifydo, the perfamwc ofthewmkfo hich i untied,I shell 0.)A RHE, WNENTIELECTR
not employ any n in any m net o e subj e• PAID
Compensation Ls sof Calif yTER SYSTEtTPATING Dat Receipt#
0 z Applicant
z 0 NOTICETOAPP ICANT:ILefe, ng this Cm a of Exemption,you should NEW RESIDENTI LPLMB. SQ.FT. TOTAL:
rGn becomeabipsuta Warker'e Com tion pmvislav (me Labor Code,you most
> forthwith comply uh such provisions or Nia pemit shm14 tamed revoked. BUILDING M
W
Z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby off met Here is a coScrod lending agency for the pMomunce of
L) O the work far whi<M1 is pemm is issuW(Sa.31197,Civ.CJ T F.LECfRIC FF,E
Lrndeea Nume
V. QTY. [ `.' MECHANICALPERMIT FEE PLUMBING FEE
F^ LendIc candy
W 1 certify mm I h E feat this application and ante rico the i above information i � ..i 4'm:. '
coned.lagrce to cam ywith ell city arm county ordinances end sumlawe rclmi to PERMITISSUANCE MECHANICAL FEE
buildingeonsmction,on hereby authorize rcprevrntatives of this city toenhar the CONSTRUCTIONTAX
L) 7 above-mrntioned pmpe for impecha purposes. ALTER OR ADD TO MECH.
F7 (We)agree to save,i cmnify and keep hemdeas the City of C Wino against
hailities,jud a1405t seswh'chmayfnenywaya eagmrasial City AIR HANDLING UNIT(TO 10,00o CFM)
in eon ce of egroni
�� AIR HANDLING UNIT(OVER IO,fX)0 CFM)
namreofApr ant/ rotor Data EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10.000 BTU) Data Receipt#
Will the applicant or fmure building occupant it.or handle hemrdon mmdm HEATING UNIT(OVER 100A(10 BTU) A
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Dean and Safety
Cada,Section 25532(x)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will thexpplichrumfuturebuilding occupom uscequipmenmrdevices whichemit BOILER-COMP(3HP OR 1 (0,1100 BTU) o �T
tmNous air cantaminnt n defned by the Bay Aree M AU Quality Management BOILER-COMP(OVER 100,000 BTU) • D
Oismn4
❑Yea ❑No NEW RESIDENTIAL MECIL SQ.IT. gyp• gl.1� 'I
I have read the harmdrus materiels requieaments under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534.1 understood that
ifbuildingdoes nmcurrently have atenant,that itis myrcuance bllityenotify the
iftheoccupant of the requirement which may be ton prior m issuance led it Ce notify he
IXcupancy.
Owne in authorized agent Date TOTAL: ISSUED BY:
OFFICE i
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