27072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
"IIINBU_IAM
RTINO B I.DIo -M.E RI AL PERMITNO.
ION APPLICATION/PERMIT PLUMBING-MECHANICAL 27072_�I 0�A
BUILDING PROJECT[BEST IF'ICATION L I G
L SANITARY NO. APPLICAA'DO�NSU///BMMl♦♦MAJ-DATE
P UNIT# LOT%PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
C GINE LIC NO:
A If4HGA FSS: ��
CO ACI': PHONE: BUILDING PERMIT INFO
IWIleas' QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
mv
1 Z PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Oy.Z Ihcrebyaffrmthat l Jetth Business
and ramsd.Code, nd my)1. gwith
maz❑ Sectionhereby suf Division Am licensed
Business and Professiatsifte,)(cmyencing wa in PANELS
131 full force and effect. /Jp� al p
< License Class Lic.p UP T02(XIAMPS
W
¢ rFir,O y Dale Contactor OV-1000 AMPS SQ.PI'.FLOOR AREA 5/SQ.FT.
'ZODK RCFI CP 0 LARATION OVER 1000 AMPS
O'G"G d d ash ublic records.
P c C til u SIGNS ELECTRICAL
I�C•��'��J Lice J
a6 cxionm OWNER- UILDF:R DECLARATION SPECIAL CIRCUIT/MISC.
y�OiU 1 hereby affirm that 1 son exempt from the Contractors License Law for the
W3fa F' following mama(Section]0315,Business and Professions Code:Any city or county TEMP.METER OR POST.
j-u4 y which mquims a permit m construe.,alter.improve,demolish.or,repair any¢weme, VK
S Y.7 Prior to its issuance,alsomquimsthe applicant bar such Permit o rile a signed statement POWER
CO that he is licensed pursmm m the provisions of Ne Convectors Lkenx law(Chapter
p.ao� 90ommeacingwinh Section]000)ofDwision 3 ofthe Business and PmfessionsCode) SWIMMING POOL ELF:CTIII VALUATION ef
yKj_y
or that he is exempt therefrom and the basis for alleged exemption.Any violatio f
�3Y Sation 7031.3 by my applicant for epermit subjectsthe applicant to ecivil penalty f OUTLETS-SW - T 5 '
Q
not mart than rive hmJrcJ dollars(550
Km O ❑ Las ownerofthe ro NEW 1 .EL m _.-SQ.FT. STORIES TYPE.CONSTRUCTION
y S3� p perry,amyem yas wiNwagesntheirmlecompc...tion,
wiilcto the wort,andthesbuctu rwti edaroffercd forxle(SccA(W4,Bminess
mJ Pmfessimna Code:The Con n i nx Law tic t apply to an owner of
propertywhobuildsarimpr sth hnndaesyg TvoTS himxlforduough hia
empl ceaprxi, I a c vem msart r�g(tlogrn_pdpefa n.fmacilheraile.If.
i OCC.GROUP RES.UNITS
however,! bu'dii vermmisyl)I thinpne ye ompletion,tbeowner. TOIAl.:
buil er w' av a fprovin a he door build or improve(ar purpou of
sale. nn
❑ , o r thevropen xdus conva lingwith licensed emorarmre to 9TY. PLUMBING PERMIT FEE -----FLOOD ZONE APN
crammer the mj n(Sec.] mess load Professtom Cale:)The Conuacuxa
License Law of applyuan erofpmpertywhobuildserimpmvestler..,and PERMIT ISSUANCE
who contracts rsuch projects with a communist Incorrect purmarm In the Contracmr's ALTER-DRAIN& T-WA'TFR'FA
License law. 1 ) FEE SUMMARY
❑ I em exempt under Sec. ,B&P C far this masonBACK 59WfROTEC17.DEVICE OUT 8 DE E
SANITARY Y_N
Owner Dam RECEIPT.
WORKMAN COMPENSATION DECLARATION INS-Fl.00R,ROOF.AREA,GOND. SCHOOL TAX YN
•❑ Ihereby affirm that l have a ceri0ateofcommotmself-insare,ora cenificateofFIXTURES-PER TRAP RECEIPT.
!Workers Compensation lnsurunceoracriifed co,thereof(Sa.380,Lab C.)which PARK ME Y N
coveall employee's under this pert. GAS-EA.SYSTEM-1 INC.4 OUTLETS EIPI'.
n mi
Policy. PbUINCJDIVISION FEES t L
Company - GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK R
❑ Certifiedcopyisherebyfumished. g
❑ Cenifedcopy is filed with the city inspection division. GREASHANDUSTRL WASTE INTERCEPTOR GRADIN
bnJ
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS
COMPENSATION INSURANCE
(This section noted not he completed iftbe permit is for one hundred dollaa(5100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
al
(certify that persom in myonceof,ar.1.f.bea nothiubject bales Wo d. shall WATER HEATER W/VENT/ELECIR
not employ any person in any manner sa n to become subject m the Worker¢' PAID
Compensation Lawsof C.lifnmia. Dam WATER SYSTEM/IREATING Dam R to,
Z Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
� LO) become subjectto the Workers Compensation provisions of the labor Code,you must
a
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE rp
W w' SEISMIC FEE C &V[a CONSTRUCTION LENDING AGENCY
IS
'Z' affirmma
1 hereby that them is a carmuctim lending agency for the Performance of I Uthe work which this permit is issued(See3097.Civ.C.) TOTAL: ELECTRIC FEE
Lenders Nume
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
U I certify!hm I have read Oils appliction and,tam that the alvve information is - ' MECHANICAL FEE
jLTacorrect.l agree to comply with all city and county ordinances and slate laws misting to PERMIT ISSUANCE
huildingconstructim,and herebymnum.mpmsaretivu of lhi¢city to enter upon the U 00 CONSTRUCTION TAX
(„) 7 nbuve-memioneJ propmyfor inspection porpoaes. ALTIiR OR ADD TO MECH.
O (We)agree m¢ave,indemnify and kap harm) ry of Cupertino against
liebilitics,'ud and ores whichm eeyaccaeageinst said City AIR HANDLING UNIT(TO I0,000 CFM)
f neon uen f gran' (Nis permit.
12 AIR HANDLING UNIT(OVER IR"CFM)
le RApplicantlCoulowtor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or future building ucupammm,or handle hazardous emmdel HEATING UNIT(OVER 100,000 BTU) TOTAL:
f na defined by the Cupertino Municipal Cale,Chapmr 9.12,end the Health and Safety
Code.Section 25532(.)? VENTILATION FAN(SINGLE RESID)
❑Yea ❑No
Will We uemmornlnr future building by the t rex equipmentQualit c Marrich emit
BOILER-COMP(3HP OR 100,110(1 BTU) EDATE
ores ur contaminant¢m defined by the Bay Arte Air Quality Memgemct BOILER-GGMP(DYI?R IOO.gIOBTU) Ja�181995
District?
❑Yes 0 N NEW RESIDENTIAL MECH.-SQ.FT.
I have mad the hmardom materials nequirereems under Chapter 6.95 of the ys qqy ur �urtpllNU
California Health&Safety Code,Sectio..25505.25533 and 25534. 1 understand that VIV�1
if the building dues not currently have a tenant,that it is my msponsibility to notify Ne
occupant of the requirements which must he met prior a issuance of a Certificate of
Occupancy. I b�9
Owner or amhoriud agent Dam TOTAL: ISSUED BY:
OFFICE