27645 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY ON CUPERTINO1LR"PT NO. f•�
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL L
-r^BUILDBVG PROJECT IDENTIFICATION '�
BUILDING ADDRESS: SANITARY NO. A1PPLICAnON SUBMITI'Al.DATE.
n t UNIT# LOT# ( — s
OWNERSNA E: PHONE: CONTRACI'OR'SNAME: LIC NO:A-Al 1111
_ a N/C CONTROL#
• ARC ITELT/ENGINEFR: LIC NO. ADDRESS: ❑
CONTACT: PHONE: �Y ;p; ..el,•i r F�.,;.�.!W BUILD1NO PERMIT INFO- '
C !L LI L
LOU ELECT PLUMB MECH
PERMIT ISSUANCE El El E] El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
=mz I hereby affirmtlut I am licensed underpmvlsionsofChapm9(commencingwith
`00 Section 7000)of Division 3 of the Business etl Professions Code,and my license is in PANFJS
CLU full f.Candaffect.
�fx/� / _�
,_Zu1 Littnse Class Lic.N UP TO 200 AMPS if
1
rn?h Dale Contncmr 201-1000 AMPS
y Z
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Z1 undersand my plans shall h used On public records.
to F-w SIGNS ELECTRICAL
Y�J Licensed Professional
-p;ce6 OWNER-BUILDER DECLARATION SPECIALCIRCUR/MISC.
'On' I hereby af=Nu I sm exempt from the financiers License law,for the
:3LLy following reason.(Section T031.5.Business and Profusions Code:My city or county TEMP.IsfEIER OR POLE DIST.
=05 which inquires a permit to cmauuct,a=,improve,demolish,or moor any strunme
;WYE prior to in issuance,also textures the applium for such permit ro file a signed moment POWER DEVICES
72p0 that he is licensed pursuant ao the provisions of Ne Contractors License I..(Chapter
9(commencing with Station 7")of Division 3 ofthe Business and Pmfemom Code) SWIMMING POOL ELECTRIC VALUATION
ty e^y
or that he is exempt thertfmm and the basis for the alleged exemption.My violation of
1-ZQ Section 7031.5 by any applicant for a permit subjects the applicant in a civil poetry a OUTLETS-SWITCHES-FIXTURES
tea more than five hundred dollars(SSW).
CFO ❑ I.asownerofNe p y wegesastlrcvwlecompeualion. N6W RESmFIv'11AL ELECTR —SQ'Fr'
�_� propmy,ormyem to edoro STORIES TYPE CONSTRUCTION
. will do Nework.ands: swmureisnoJnandedorawmfmde(Sey to run Erma¢..
and Professions Cade:The Contractor's and
Law does amt apply to a owns of
prognrywho
yeas,pdsmimgat such improvements
dousuch
aximahimselfor for ugh We.
OCC.GROUP RES.UNITS
cone
however,
m ees dingor tlmtsuch improsold wi arcnm maximal transmits-
If, -
huilder will
eavete human rovemanuhat he id not Wild of completion,theawnm- TOTAL:
builder will have the burden of giving thea he did not build in imgove for purpose of
W..). jf� uav+.rusn...s.�rAaravax ,,s� x
❑ I,uawnerofthe Mro ny.amexclusivelyconlnciing with licensedwnRactonto Q? #iY�"IL iPLUMBING PERMIT ;iv;Ybg�:+x-,p- r?FEE ' FLOOD ZONE APN
terrte x+a:aaax.vtvassd.<.Ei?!RE nU":..rwv-;_
coatruct the project(Sec.70,14,Business and Pmf nasions Cade:)The Conoco". PERMIT ISSUANCE
License Law dos not apply wan owner of properly who builds m improves thereon,and
who contracts for such projects with.confirr (s)licensed pursuer to the Commerce's
License Law. ALTER-DRAIN&VENT.WA , ff FEE SUMM_ARY,",., kjtk,'
❑ 1 am exempt it,,Sm. ,B&P C fm thisrecon O T SI E 17
BACK FLOW PROTECT. 'TCR SANITARY Y N
Owner Due RECEIPT#
DRAINS-FL . OOH,AREA,COND.
WORKMAN CO MPENSATIONDECLAPATION SCHOOL TAX Y N
• ❑ Thereby afOrm Nett.lave acenificsa ofcousem ao self-thsurt,macatifuaaf RECEIPT#
RES-PER TRAP
Warkcri Camgraeaion haureceon certified copy thereof(Sec.3800.Lb CJwhich PARK FEE YN
ars allemployee's under Nis permit. GAS-EA.SYS M- .40UTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYS 4(EA) ellPLANCHECK FEE
[ICertifiedcopy is hereby funinhed.
❑ Cenified copy is filed with the city ivpEA
ccdon division. G S WAGRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' SOILS FEE
COMPENSATION INSURANCE
(This aenion neednmbe completed if Ne:gmtit is kenichundreddollars(5100) S -SANK STORM .200FT. ENERGY FEE
or lass.)
I certify that in the performance ofNework fm which this pemua is issoed,lshell WATV HEATER WNEpKkEEIZR 00
not employ any person in any manner ao as a become subjera m Ne Workers' PAID
Compenamm Lawn of Cafifmda Dao ATER SYSfE TING Dao Receipt p
Z Applicunt
Z 0 NOTICE TO APPLICANT:If,afar makingthis Certificates of Exemption,you should W NTIAL PLMB. SQ.Ff. TOTAL:
r rA become subjon to the Wmkars Compensation provisions of the labor Cade,youmuss
x ; forthwith comply with such provisions in permit shag he dermadvo
remixed. BUILDING FEE
y Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Nat there is a ctnspunian lending agency for Ne grfonmece of
O TOTAL: ELECTRIC FEE the work for which this pamit is issued(Sm.309],Civ.C.) U
Lender's Namerxa w
jF Lenders Address MECRANICAL'PERMTr( "'l .- vS4 FEE'{ PLUMBING FEE
U I minty that 1 have read this epphOtiml and NIC thin NC five information isLL)
>" a comet.lagecerooumpiy with of city edeounry oNineces and sate laws mining ao PERMIT ISSUANCE MECHANICAL FEE
-_ Cn buildingmestruction.and hereby amhmin teprcsenabvesof Nis city former upon Ne CONSTRUCTION TAX
,J Z abov>memimad property for inspection puTners. ALTER OR ADD TO MECH.
(We)agree to savr,indemnify and kap hamdws the City of Cotentin.siumn
liabilities,judgmcna,costs and expenses which may in any way acme against sod City AIR HANDLING UNIT(TO 10,00)CFM)
in consequence of the Framing of this perm{
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of AppiicanVConoanor Date EXHAUST HOOD OVIDUCT) PAID -1=�—
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt it
Will the applicant orfuture building mcupam more or handle hau.dmus ma¢dal HEATING UNIT(OVER IW.WB BTU) TOTAL: Q
as defined by the Cupertino Municipal Cade,Chapter 9.12,ed the Health and Safety
Code.Seniors 25532(a)^
13 Yes ❑No VENTILATION FAN(SINGLE RESID)
DATE
Will thcepplicemrfumre building mcupanmuequipmentordeviceswhich emit BOILER-COMP(3HP OR IW,OOU BFJS1AVCD
TU) IIYY JJ''
haurdous air contaminants as defined by the Bay Arm Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distrust? 12n q(�(�['
Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. JAN 2 0 995
1 have read the haurdous materials requirements under Copper 6.95 of the
California Health&Safety Code Sections 25505,25533 and 25534.1 undersand that CITY Vr WrtflI)NO
if the building does out currently have a tinea,Bear is is my mipmribiliry n notify the
mcupant of the requiremcn¢which must he met prior to issuance of a Certificate of
Occupancy.
Owner or authodudagenl Date TOTAL: ISSUEDBY: TQ,`^L p A
OFFICE