27961 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOrarrRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-
MECHANICAL. A�'I
BUILDING PROJECTIDENITFICATION J 1
BUILDING ADDRESS4 I SANITARY NO. APPIJCATIONSUBMTITALDATE
O UNIT LOT# `
OWNERS NAME I PRONE: CONTRACTOR'S NAME: LIC NO:
YV.7 Qdgo NPC CONTROL#
ARCHITECTIENGINEER: LIC NO: ADDRESS: ❑.
CONTACT: PHONE: BUILDING PERMIT INFO
QTY_: ""' 'HGECTR[C,BHRtvIIT FEE
I BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICthat( DCnN mCpmviionsof DECLARATION APPLIANCES-RESIDENTIAL - JOB DESCRIPTION
O CGZ (herebyaBirmfiSEDiCONTRA TORS DE LARATer9(commencingwith P—I `SW_w 1`-1U_-�•U_a sss///�����_ ��#,,,
1400❑ Section J000)of Division 3 of Ne Business and Professions Code,and my human is in PANELS
F�bW full force anAef en 6pACL R UP T0200 AMPS
<Z Licrnm lass Lic.#
a <n Date Conne.rn. l 301-1000 AMPS S Ff.FLOOR AREA f/SQ.FT.
ZOOt 4 ARCIITfECTS DE A TION OVER I"AMPS
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O Z,O I understand my plans shall be used as public records.
r Ly L c l SIGNS ELECTRICAL
4 9�,,j Licertud Professional
Fj G OWNER-BUILDER DECLARATION the Co ATION SPECIAL CIRCUIT/MISC.
O0F I hereby affirm that 1 am exempt from the Contractor's Cs License Law for the
n1 vos5 whichfollowir,doesn(Seaio mmor703 ,Busimr.imrPmfdemolx Code:Any city or many TEMP.METER OR POLE(NST.
prior requires issuance,permit ce direst a alter,improve,demolish,fi repair ed swmum
�T0 donne is lcensedrsont to to tPrvisiosocant formchtocor's fileasie Lad statement POWER DEVICES
�L�p donhewith Suanuotheproviaiomaof thetheusiness License Law(Chapter SWIMMING POOL ELECTRIC VALUATION
1do� 9(commencing ingwith Section Land the Division loftheed c.rsaand.An, iolaCode)
W_m Sdeat ections 01.55 my apromandthe for a Permit
subjeasegedexemant to An,violation of OUTLETS-SWITCHES-FIKTIJRES
CZa $or..1Gurfiv my camrs($permitsubjeaethe epplicannoecivil penalty of
I.asoanfvehepmp ollars(yempl NEWRFSIDENTIALELECTR _SQ.FT. STORIES TYPECONSTRUCTION
yC�m ❑ oche wok,andepropeny,ormyemDlnyemwithwagmuthehec.7(mpewdw.
,3.. will dothewons andthe he Cmucture isnot imm�dese Imsdoeoffieredl sa.,apply 1.an Business
and roo,wh professions Cdc:The Contrectors License Law does or apply if rt owner is
ownerrywyers,pdevidedmvatheman,mdwhodoesmch work hiasselred for ughhis OCC.GROUP RES.UNITS
employees,pmvi or i Nat such improvementsarenot imendedoroffend formic.1L
however,the building or improvement is sold within one year of completion,the owner TOTAL:
builder will have the burden o(proving that he did not build or improve for purpsrs f
aale.).
❑ Lus owneroFlhe propeny,am exdusivelycontracting withlicenudmn meta QTY. PLUMBING PC FEE FLOOD ZONE APN
construct the project(Sec.](M,Business and Professions Code:)The C tractor's PERMIT IS ANCE
License Law does not applym an ownerofpmperty whobuilds orimprovu ermn,and
who contracts for such projects with acontractor(s)licensed pursumtto Coneracrofe
License Law. ALTER-DRA &VENT-WATEll FEESUMMARY
❑ 1 am exempt under Sec. ,B& C for this reason 0 D-
BACKFLOWPR TELT.DEVICE SANITARY YN
Owner ate RECEIPT#
DRAINS-FLOOR. F,AREA.COND.
WORKMAN COMPENSATION DF. ARATION SCHOOLTAX YN
❑ Ihcrebyaffirmthar l haveecmiIII mfcon ttoulGimure,orumrifica¢of RECEIPI'N
FIKTURFS-PER TRA
Woheri Cnmpemationhrsm eac=1 crate 01 py therm See 3800,LabCJ which PARK FEE Y N
ars all employees under this permit. GAS-EA.SYSTEM-1 W\4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-CA.SYSTEM-OVER ) PLANCHECK FEE
❑ Cenifid copy is hcraby f 'shed.
❑ Camfiedcopyis Ned ".' city inspection division. GRE ASEfiNDUSTRL WASTE INNkCEPTOR GRADING FEE
CERT( ATE OF EXEMPDON FROM WORKERS' GREASETRAP SOBS FEE
COMPENSATION INSURANCE
(Thissectionned Dribs completed if the permit is(Drone hundred) tars(EI SEWER SA A ORM OOFf. ENERGY FEE
mleak)
I certify that in the of the work fm which this permit isiu WATER ILEA - /VENT ECTR
not employ any person in as be be, subject ken' PAID
Compermhow Lawsof Celifomiam Date so e A SYSTEM/TRE NO Date Receipt
02 Applicant
,Z It IN I'V
0 NOTICETO APPLICANT:If.afterNLENDI
rdfi em ron.yo should NEW RESIDENTI PLMB. SQ.FT. TOTAL:
fn become subjmuo the Wmkefe Comision exborC e,yo
forthwith comply with such provisiot shad be desc / BUILDING FEE 11
IIJ r CONSTRUCTAGENCY SEISMIC FEE
Q I hereby affirm that there is a ci agenO the work for which this permit is issu ,Civ. J TOTAL: ELECTRIC FEE
f�--+s Irnder's Name
C) F� Lender's Aedresa Q ," MECHANICAL PERMIT FEE PLUMBING FEE
WI certify that 1 have read this application and suede Nat the ve information is M[CHANICAI.IT9
0.. correct.l some to comply with all city and cowry oNinmae and s laws relarm PERMIT ISSUANCE
Vj buildingmmracrion,and hereby mthorizetepremnutives ofthisctryt nthc CONSTRUCTIONTAX
V above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and kap harmless Ne City of Cupertino against
liabilities,judgments,mats and expenses which may in my way secmeagaimt said City AIR HANDLING UNIT(TO 10,"CFM)
in m ucnce of the ting o omit.
AIR HANDLING UNIT(OVER 10,000 CFM)
grumm ofA a V mmctor Date EXHAUST HOOD(WIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt If
Will the aw icant or future building occupant store or handle hazardous materiel DATING UNIT(OVER 100,"BTU)
m defind by the Cupenino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 21332(e)1
11 Yea 13 No VENTILATION PAN(SINGLE RESID)
Will theapplicant orfmum buiWingoccupant uxequipmem ordeviaswhichemit
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE bArE
aawdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
istnct'1 11 /�
Yes ❑No NEW RESIDENTIAL MECH. SQ.Pf. P A ' f)
I have read the hazardous materiels 5505.2menta under Chapter 6.95 of the API?
I ��
California have
Health&Safety r de,$mono 35305,ement and 25134. 1 u r 6.95 f thuste �'1�.!
if Ne building docs not currently have a dent,that it is my responsibility to notify the
occupant of the reyuimmeme which moat be ran prior he issuance of a Certificate of C/ V
occuopancy.
Owner or authorized agent Data TOTAL: ISSUED BY:
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