27552 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO B ILDIN,-ELEIAHI AL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
11111 LDINGPROJECT I DENTIFICATION 5 5
J J
BUILDING
ADDRESS:
�� SANITARY NO. APPLICVGONSUBMITTALDATE
tvK.�� UNITp M LOT# .
O NERSNAME. PHONE: O E: .�al�/ I
`D R • L Ec $69-2 9A /SP.1 E x NC coNRo x
✓rT
yI RCHITEC/UNGINEER: LIC NO: DRESS: ❑
1r/�✓ra.✓ .Wi. �iSl�•P lfd� C�4.
fol CONTACT. PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
C�UHK YrTnNYw 3� ( .X SOT SDC BL[C' PLUMB MECH
PERMIT ISSUANCE fL'gP 'lay[T_�ilOpl`
LICENSED CONTRACTOR'S DECLARATION pppLIANCES-REgIDENTIAL LOB DESCRIPTION
OWz Ihereby affirm that am licensed underprovisionsofaapter9(commetmingwith
POO Section]000)of Division 3 ofthe Business and Professions Code,and my license is in PANELS T
y.6ZE full force and effect.
FZW License Class Lm.0 UPT02MAMPS
m 6 p. Dare Contractor 201-Il"AMPS �
ZpyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FL LA S1SQ.pT
O Z�❑ I understand my plans shall be used as pablw oremd. ////���� L�
SIGNS ELECTRICAL. I
6Yce Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRNIT/MISC.
�0.CC4 NO y� 1 hereby affsnn but 1 am exempt from the Contreclor'a License Law Boom
41LLOvt following reason.(Section 7031.5,Business and Professions Corm:Any city or county TEMP.METER OR POLF:INST.
JQ which requires a permit to construct,almq improve,demolish,or repair any structure
5C'te3NY� prior to its issuance.at.res,mom the applicant for cuchpermit m Bleu signed statement POWER DEVICES
W C, that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter
0. 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALLJJPON
_yo or that he is exempt and the basis for alleged eaempoion.Any violation of 01 Cr /"�'
Section]031.5hyunyapplicantf,,,.,.it,ubjeacthrapplicaruo.civil penalty of ",ITS-SWITCHES-FIXTURES Gvy`\i
not mort than f ve hundred dollars(8500). LCfR
qqpm% ❑ Lasownerofthepropeny,ormy as. hwage stheirsolecompensatNEW ftESIDIiNTIAI.EL _SQ.Pr.
inn. STOVIES TYPECONSTRUCTION
5_ villdothe work,andthe commute iso dmmm or Ie(Sm.]044,9.airesr
and Professions Code:Tho Con m r' .crusel. doe m uMly m un owner of
pmpenywhobuildsmi ow ,wdwhocsworkhimselfortru
hughhis
empl,wes,powid m
improv or intended or offeredforVitc.If, OCC GROUP RES.UNITS
however,the building lc vemrmissowh mcye.rofcample,m,mrowner-
huilderwillhavetbebuNe of .,in at id not build or improve for purpose of
sale.).
❑ L.mw,w,.fthx'm'mYex isely mommining with licensed contractors to QTY. PL GING PERMIT FEE FLOOD ZONE "NN
construct the project(Sea. 4, meas and Protractors Codm:)The Combotore
License Lawdoesnot ytoan erofproperrywbobuildrorimpmvesthereon.end PERMIT UANCF:
wbscanlracts forsuch pmjmt ith aconwnogsl liunsed pursuen0othe Contractors
"em.Law. A R-DRAIN ffi VFN -WATER(PA) FEESUMMARY
❑ 1 um exempt under er. ,D&P C for this reason BACK FLOW PROTECT. VICE SANITARY TY SIDE N
Owner Date DRAINS-FLOOR.ROOF,AR .GOND. RECEIPrp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby offrte thmlhave acenifcateofconsentmnelf-ins. ac oEenteaf FIXTURES-PER TRAP R
PT
Wmkers'Compeneation lnmmnceorattrtifiedCopy Hereof(S .3800,labC)which PARK FEE Y N
covers all employx's came,this permit. GAS- .SYSTEM-IIN 40UT fS #
Palicyp BU1PTqWIONFEFS
Company - YSTE V R PLANCHECK FE
❑ Certified copy is hereby famished
11Certifialcopyis filcdwiththe city inspection dais n. ASt STRL STE RCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM 4eBAS P SOILS
COMPENSATION INSURAN
(Thiscecti...e notbecompletWifthepctmloisf\ichundreddoll I E EM-SANITARY TORM EA.200FT. ENERGY FEEor less.)
Icertifythinintheperformanceofthe workforwhicmit isissae. 1 WATER HIiA /VENT/ELECTR
not employ any person in any manner soos to becocti m the Wor m PAID
Compensation laws of Colifurnim. Date WATERS FM/IRFATING Date Receipt#
O z Applicant
z 0 NOTICE TO APPLICANT.If,after making this Certificate of Enem ion.yoo ahould NEW SIDENTIAL PLACE. SQ.FT. OTAL:
rt—t beeome subject to the Worker's Compensation provisions of the Labor e,you must
a7 forthwith comply with such provisions or this permit shall be deemed rev etl. BUILDING "s's's.
w (] CONSTRUCTION LENDING AGENCY SEISMIC, rE
1 hereby off.thin there is u construction lending agency for the perfnormwe of
U O the work for which this permit is iscued(Sec.3MG.Civ.C.) O E E \
ze
Lenders Name
D" Lenders Address QTY. MECHANICALPERMIT FEE BIND Ee
0 U I certify that 1 have read this application and state that the above information is
M NIC L FEE
In marten.1 agree to comply with all city and county nwiwc ordinances and stem laws rup ng to PERMIT ISSUANCE
U In z above-mentioned
hembyamhorizemprtaenmtivcsof this city toenterupon Ne CONS U ION TAX
above-mcmionW property(mins tv purposes. ALTER OR ADD TO MECIi.
(We)agree m sa inpemnify d!keep loom s the City of CLpenino against
liubilitics,jud sN dex uses hich mayi any we ¢mule agaimt;cid Ciry AIR HANDLING UNIT 0010,000 CFM)
into eq tin ispeit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Sib o slppl�c vacs au EXHAUST HOOD(W/DUCT) PAID
I IAZAROOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,"BTU) Date Race'
Will the applicant or future molding occupant start or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safery
Cada Sxtion 25532(x)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑Na ��
ISSUANCE DATE
Will thcapplicvntnrfuture buildingcecupam umequipmcnmrdevices whichemit BOILER-COMP(3HP OR 100,fXq BTU) Bq
amdous air conmminants a defined]by the Bay Area Air Quality ManagementBOILIiR-COMP(OVER 100,000 B'IYI) r
•isvin]
❑ 13d 1
Yes No NEW RESIDENTIAL MECH. SQ.FT. A 1��
1 have mad the havrmam
fu a riAs me unlmemr under Chapter 6.95 of the 5
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that Cl7Y ser
ifthe noddingdoes not currently have a tenant,that it is my responsibilitym notify the Vt /l
occupant of the re9uiremenm which must be met prim to issuance of a Certificate of
Occupmcy.
Owner or authorized agent Date ISSUED _
OFFICE