27177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIO NO APPLICATION/PERMIT P1.RMrrlgo. 27177
BUILDING DIVISION DING PLUMBING MECHANICAL
BUILDING PR(ANC'I'IDEN'TIFICATI(IN
BUILDING A/DURESS: ///� /���(�/� SANITARY NO. APRIGTION SU(B/MfITAL DATE
/ /� V gr• f/r♦� UNIT LOTg
O NF.RSNAME: PHONE: CgKR✓ACI'OR'SNAME: .wa` IC NO: l 1.
4/44,924 1d s •z1 L-7 U//�J J G NIC CONTR g
J
1/' TF f/ETIGIN 1 A , A,/ ,40 ,
77
ONI'AUI PHONE 'a
I.FILCRI'RI�C PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE El 1 -0
LICENSED MISTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
0.'Z I herebyalfond that lam licensed underprovisioavofChapecr9(conuneneing with
yy y0y�0 Section 7000).(Division 3 ofthe Business and Professions Code,and my license is in PANELS
<zVg fail
�Clasd e�fffi!I-.�-3���sc., � 3 UP TO 200 AMPS
y<d Due_(-LLL L-L Cmtdscur 201.IOOO AMPS
rOzaZ ARCHITECTS DECLARATIONSQ.FT.FLOOR AREA $/SQ.FE
I understood my plana said be used m public records. OVER HIM AMPS
OZ-0
N
SIGNS ELECTRICAL
Littered Professions)
iyR u
OWNER-BUILDER DE CLARATION SPECIAL CIRCUIT/MISC.
0( a 1 hereby offirm(Se that 1 an exempt from the Conions Co e:Ame law for the
rel 3 Q y following reason.(Section 70313,Business and Professions Cade;Any dry or only TEMP.METER OR PoIE MST.
NC) which requima n permit to construct,eller,improve,demolish,ri e a sig any structure POWER DEVICES
thione itslissumtt,alamint tousthevisionsocant for the ch Committt to ees
Lice signed statement -
Op that he is licensed pursuanuo the provisions of the Convectors License taw(Chapter
9(commencing with Section 7")ofDivision 3ofthe Business and Professions Code) SWIMME4G POOL ELCCTRIC VALUATION
radial howesou,nherefrom sndlhebasisfmthedleinclammption.Anyvioletionof OUTLETS-SWTfCHE3-FIXTURES
iza Section 7031.5 byany applicwtforapcionatuhjsutheapplicanuoa civil pnWtyof
not mom than five hundred dollars($500). NEW RFSB3ENTIAL ELECfR S .FT.
❑ I,aaowneraftheproperty.nrmyemployeeawithwagesudmirmlecompernation. Q STORIES TYPECONSTRUCTION
L will do the work,and the structure ismaintendedorofkmd forsale(Sec.7004.Business
ad Professions Code:The Contractors License law does not apply to an owner of
poiamy who brei Ids m improves thereon.and who done s uch watt himul f m through his
OCC.GROUP RES.UNITS
.am employees,providedthat such improvements arcnotimrrofe moffered(orsate.If,
however,the b o theg ur improvemem is rat he didn one veer of completion,the owner TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
sale.).
❑ Looconchofthetnipemy,amexdusivelyconlmetmg with licensedcontmetars to QTY. -PLUMBING PERMIT FEC I1.00D]ANE APN
construct the project(Sec.7004,Business and Professions Cade:)The Contractor's
License Law does not apply to an owner of property who builds or improves thermon,and PERMIT ISSUANCEac
who cantru forsuchim jects with aommumensis)licensed Firemanto We Contractor's
[.i.e.Law. ALTER-DRAIN&VENT-WATER(EA) FEE ARY
❑ 1 ran exempt under Sec. ,B&PC for this reaam BACK ROW PROTECT.DEVICE
S ITARY Y N
Owner Date— DRAINS-BOOR.ROOF,AREA.COND. RF.CEI M
nt
WORKMAN COMPENSATION DECLARATION SC ooUTAX Y
❑ Ihttcby effrm shmlhnveecemificate ofconaenua self-insurc.mecenificem of FIXTURES-PER TRAP RECEIPT
Workers Cmmpeosation Insure.m a catiEed copy thereof(See3600,Lab Cd which PA KFEE Y
/ EIPT
covers all employee's under this permit. GAS-EA.SYSTEM-I INC. OUTLETS BUILOM RDC ISION ES
Policy M
Company GAS-EA.SYSTEM-0VER4(EA) PLA CHECK FEE
3 ❑ Cenifiedcopyisherebyfumishad.
❑ Certified copy is filed with the city inspection division. GREASFpNUUSTRL WASTE INTERCEPTOR GRA ING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRA' soil IEE
COMPENSATION INSURANCE
(This senior nad not be completed if the permit is for me hundred dollar($1Wd SEWER-SANITARY-STORM FA.200M', ENE GY FEE
or It
Icortify that in On, oftmenca of to work for which this poral,is issued,I shall WATER HEATER W/VENT/ELECTR
nm employ any personany manner an a to become subject to the Watkin' PAI
z Compensedonlawsof Cdifomia. Dam WATER SYSTEMIIREATING Date Rettipt#
NOTICE
z� O NOTICE TO APPLICANT:If,der making this Certificate of Pxemp0on,you should NEW RPSIDENTL4L PLMB. SQ,PT. TOTAL:
E-I tibecame subject to be Workers Compensation provision,of the labor Code,you must
7 BUILDING FEE
LL forthwith comply with such pravisiom or this pnmit 0.11 be deaned invoked.
C
kkI (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
z. I hereby affirm that them is a construction lending agency for the performance of TOT ELECTRIC FEE
u O the work for which this Form,is issued(Sec.3097,Civ.CJ
Lenders Name
IT.
F' Lenders AddressQTV MECHANICAL PERMIT FEE PLUMBING FEE
V I comity that I have read this application and arae that the above information I. t - MECHANICAL.FF.E
�^ cortecL Iagree to comply with allmry and countymbassubes and sum laws mlm gm PERMIT ISSUANCE
V z buildimgconstmetion,and hereby authorix representatives ofthiscity wemerupon the CONSTRUCTION TAX
above-mentioned property for inspection pompous. ALTER OR ADD TO MECH.
(We)agree to save,indemdfy and kap hatmlcss the City of Cupertino against
limilitia,judgmene,costs sndexpenses which may in any way wermag staaid Ci AIR HANDLING UNIT(TO IO,OWCFM)
in consequene granting.(this permit.
HANDLING UNIT(OVER IO,WOCFM)
Signew o A t onrutor ea. EXHAUST HOOD(W/DUC'D PAID
HAZARDOUS MATE DISCLOSURE, HEATING UNIT(TO IOOAOOBTU) Dam Receipt#
Will the applicant or future building repeal sora m handle hazardous mo red.) HEATING UNIT(OVCR 100,,00 BTU) TOTAL:
as d fined by the Cupertino Municipal Code,Chapter 9.12,and the Hedth and Safety
Cale,Section 25532(a)7 VENTILATION FAN(SINGLE ESSIG) _'
❑Yes ❑No
is
Willtair continuants
building by the ay Aepmir mdevic Management
BOILER-COMP(3HPOR 100,000 BTU) dSSUANCF,DA
Incautious air ammmiwntt ss defined by the Bey Area Air Quuliry Management BOILER-COME(OVER IW,Iy10 BTU) OCT � Q
Dinner? b t O
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT, 7
�^ 1 have read the Intimations materiels requiremm
es under Chatm !`I
r 6.93 of the II
CuEfamia Health&Safety Code,Sections 25505,25533 std 25534. 1 understand that
ifoccupied ofntghedrequirements which Is,mot prior
s to yi vreusmpocnesiobfilaityCtCertificatenifotciufyte thof
Occupancy.
Owneroramhodzed agent Dam TO L: ISSU Y:
OFFICE