27772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO •- RICAL RICAPERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 27772
BUILDING PROJECT IDENTIF'ICAT'ION I
BUILDING ADDRESS: 1N� SANITARY NO. APPLICATIONSUBMITTALDATE
6693 di f- 01.4 rs"we- UNIT# LOTH 2
O '�SNAME: Qr1 P}igN ����CONI CTOR'g NAr1E: u s LIC NO: S.-DAT
[LJ 3r� G 2,6
NIC CONTROLp
DA
RCHIMCgENGINEEK: LIC NO: ADDRESS:
1898 Alt Drive San Tose 9S/2
CONTACT: PHONE: BUILDING PERMIT INFO
QTY, ELECTRIC PERMIT FEE
E I/ser J�Q
3,) 57_
9 5-3823 BLDG ELECT' PLUMB MECH
PERMIT ISSUANCE OW 8I 1:1 11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 1108 DESCRIPTION
Qmz I hereby affirm that l em licensed underprovisi.ns ofChapter9 marrmencingwith
Poo faction J000)o(Division 7of he Business and Professions Cods,and my licrnuie in PANELS
FjFY-yE full force enJ effete ��
F y W LicenseClass Lic.N UP T020o AMPS
y j y Dole Contractor 201-1000 AMPS S FLOOR AREA E/SQ.FT.
ZOooz ARCHITECTS
T'S DECLARATION OVER I"AMPS
Q.
fT.
O'Z,-'O 1 undersnd my plans shall be used as public records.
SIGNS ELECTRICAL
Q Licensed Professional
� a OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. late
.00
WIO a
truth, from Nm 1 vn exempt from Ne Conuacto/s LicenseLow for Ne
�FIaN following....(Section J031.5,Business and Professions Code:Any city Or only TEMP.METER OR POLE INST.
O
1❑❑.... which requires a Permit to construct,niter,improve,demolish,or repair my swcture
dcoi� pd.,o its issuance,also requires the applicant foruuch permit to riigned leasstatement POWER DEVICES
am K
<0 that he is licensed pursuant to the provisions of the Contractors License law(Chapter SWIMMING POOL ELECTRIC d o�' 9(commencing with Section 7W)of Division 3 of the Business and Professions Code) VALUATION
yYj'^y or that he is exempt herefrom and the basis for the illegal exemption.My violation of OUTLETS-SWITCHES-FI%TURFS
6 Section 7031.5 by my applicant for a permit subjects the applicant o civil penalty of
G
not more than rive hundred dollars($500). NEW RESIDENTIAL E-LECIA 5 .FT.
tY ❑ I,esownerofdhepropeny,ormycmplayceswidhwagcsasthcirsolecompcnotian, Q STORIES TYPE CONSTRUCTION
a3� will do the work,and me stractum is not intended or offered for sake(Sec.7044,Business
and Professions Cade:The Contractors License Law does nm apply to an owner Of
propcnywhobuildsorimpmves Nerenmandwbod.suchoomt himself.,thum,hhis
OCC.GROUP RES.UNITS
ownemployees,providedthatsuch improvementsare ne imendedorof@rcE for ole.If,
hunter ,will
building umlen of une.I is rind within.build Or completion,the owner- �-
bale.). will have the burden of proving that he did not build m improve for purpme of
❑ I,as ownerofthe Prrpeny,am exclusivelycommcting with licenaedcontracmrs to QTY. "PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business end Professions Code;)The Commcrors
License lawdoes not applym an ownerofpropenywhobuilds orimproves thereon,and PERMIT ISSUANCE
who contracts for such projects with.commends)licenmd puramotto0¢Cantocora
License Law. ALTER DRAIN&VENT-WATER(FA) FEE SUMMARY
1 not escort"underS ,B&P C for this men SIDE FEES
,. .. BACK FLOW PROTECT.DEVICE SANITARY YN
er D.0 RECEIPT
DRAINS-FLOOR,ROOF.AREA.COND.
WORKMANCOMPfierd. ON .LARATIO SCHOOLTAX Y N
❑ IMmby affirm Nm lheveacenificam.ferns Ito ulGinsurc.ore certificate of FlXTURES-PER TRAP RECF.IPI'N
Workers'Compensation Insurance or acenified copy dhamof(See.3800.Lab CJ which PARK FEE Y N
covers all employer's under this permit. GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPTN
Policy N BUILDING DIVISION FEES
Company qS- TEM-OVER4(EA) PLANCHECK FEE
❑ Certified copy ishereby famished.
❑ Cmificd copy is filed wiN Ne city inspection division. GREASEONDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSOREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hemmplmed ifthe permit is forone hundred dollars($100) SEWER.SANITARY-STORM FA.200FT. ENERGY FEE
or leo.)
(certify that in the performance of the work(.,which this permit is i...ad,Ishan WATER HEATER WJVEN/ELECTR
net employ any person in any manner so as to became subjeet m the Worker% PAID
Compensation Lawsof Califomia. Date WATER SYSTEM/1'REATING' Dam 0. ptN
r, Applicant
NOTICE TO APPLICANT If.after making this Certificate of Exemption,you sho d NEW RESIDENT( LPLMB. SQ.FT. TOTAL:
become subject to the Workers Compensation provisions ofthe Lobar Cale,you st
forhwith comply with such provisions w this pernit.hall od deemed revokd. BUILDINI G9
CONSTRUCTION LENDING AGENCY SEISMICF
Z I hertby effimt Ihm there is n consnucti.n lending agency frnhe perfMmun of
the work for which Nis permit is issued(Sec.3097,Civ.CJ TO ELECTRIC FEE
Lender's Name
0 Lerbe rAddress QTY. A1C•CITANICAL B HT FEE PLUMBING FEE
kUTI1 certify Nat I have mud dais application and sons that the above in6rmatirn is MECHANICAL.FEE
(h, must.l agree to comply with all city and county oninances and stem laws aiming to CE
building constmetion,and hereby authorize representatives of this city to enter upon the
above-memiond ro ry for ins C ALTERORADDTOMF.CH.
t CONSTRUCTION TAX
U ,Z pe pec ton purposes.
(We)agree nt save,indemnify and kap mayinharmless dm City of Cupertino against
unbilAes,judgme menus and expenuewhich may in any way accrue against said City AIR HANDLING UNIT(TO 10,(XIOCFM)
N coddle a sof the granin (Nis pe id. �\
n �. N4 AIR HANDLING UNIT(OVER IOA00 CF M)
Si,ffimamfA,ImmoCmoomt.1 6 1Dam EXHAUST HOOD(W/DUCO r PAID
HAZARDOUS MATERIALS DISCLOSURC HEATING UNIT(TO 100.000BTU) Dam ReceiptN
Will the optimum or future building occupant store or handle lacerations material HEATING UNIT QVERIOg000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)'1 VENTILATION FAN(SINGLE RESID)
❑Yes ❑NO
Will daeapplicamorfaturebuildingamt cupmeemica
quipttteordevwbich emit BOILER-COMP QUIT OR 100,000 BTU) I$${IAtlCB DAfI'E
hazardous air concominans as defined by the Bay Area Air Quality.Management BOILER-COMP(OVER IM.W BTU) f /N, 1 {VJ
District? �]
❑Yes 13 No NEW RESIDENTIAL MECH. SQ,FT. MAR 21995
1 have mud the humorous materiels rcgairemem.under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534.I understand that CITY Ut uurEHf INO
if the building does not curt ma,have a tenant,that it is my rcspomibilhy m nmify tae
occupant of the mquircmens which must be met prior to issuance Of a Cenlf¢are of
Occupancy.
Owner erra dusnized agent Data TOTAL: ISSUED BV:
OFFICE