27253 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEUrRIUAL PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 27253
BUILDING PROJECT IDENITFICATTON
BUILDING ADDRESS: SANITARYNO. APPLICATIONSUBMITTALDATE
1 S a b-slob UNIT. LOT N
OWNI'RS NAME: PtIONE: CONTRACTOR'S NAME: LICNO:
C . NIC CONTROL.
CUPS r- e - -
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
O F
CONTACT: t PHONE: �, •."+."� ws BUILDING PERMIT INFO _
QTY ;'� '� r ELCTRIC PERMIT. FEE _
ri`�sS:G y'"{.-.-;es` Rt „sect• BLDG EaLs�E�Cf PLUMB MF.CH
PERMIT ISSUANCE � T El 1:31
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
nwz Ihereby affirm that l amlicensxt underprovisionsofar,wr9m
(ccmencing with s
I1WCC Section 7")of Division 3 of the Business and Professions Code,and my license is in ..NFL's
FdEt Zw ,u force andeffe} 3 $`G��
License Class Lic.N Y S UP TOS AMPS
y<y Date{N('� Conhumr 201-1000 AVS
z Orn'3 ARCHITECTS DECLARATION OVE0.1000 AMPS SQ.FT.FLOOR AREA SISQ.FT.
O Z p—c.p I understand my plans shell be used es public records. o
F,4 2 J SIGNS ELECTRICAL
� yu Licensed Professional OWNER-BUILDER DECLARATION SPECIAL CIRCUMMSC.
{is(,OLaY 1 hereby affirmNat 1 sm exempt from the Contractors License Law for she
t+I40¢ fallowing rcoson.(Sstion]031.5,Business and Profeaeiorxs Cade:Any city or county TEMP.METER OR POLE INST.
..1 which rec,ioes u pema,so construct,alter,improve.demolish.oe repair any structure
Y� prion.its issuavm,.Iho requires theapplicant for such permit fit ..ignW.tatement POWC0.DEVICES
C Q O N
0
at he is licensed pursuant to the provisions of the Contractors License law(Chapter
� 9(codamencing with Section T000)af Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
_m or that he isexempt therefrom and the basis forthe alleged exemption.Any violation of OUTLETS-SWRCHES-Fl%TURES
Section 7031.5 by any applicam fm em
a prit subjects the applicant..civil pendty of
�i t more than five hundred dolbn($KID).
W $ 13I,asownuoftheNoprny,ormyempinyeeswithwageswtheirsolecompensation, NEW RESIDENTIAL ELECIR —SQ.FT. STORIES TYPECONSTRUCTION
y will domewmk,and the structure is not imendedoraffired for We(See,7o44,Business
and Professions Code:The Commodes License law does not apply to an owner of
properly whobuildsor improves thereon,and whoduessuch work himulfmthmughhis
employeeapmvidedlhatsuchimprovementsaren.tintend4 mofferMfm Wo.If, OCC.GROUP RES.UNITS
however,the building mimprovemem is said within one yearofcomplefiootheowner-
builder will have the burden of proving that he did not build or improve for purpose of
we.).
ElLas ownerofthe pmpenm
y,aexclusively contracting with licensed contrxwow QTY,h',. .PLUMBING PERMIT FEE PLooD 7ANB APN
construct the project(Sec.7044,Business and Professions Cole:)The Contractors PERMIT ISSUANCE
Li censelaw does not apply w an ow rte of prapefty w ho bui Id.m improve.oteteon,and
who cmumcts for such Projccss with a conlnnods)licensed pursuant o the Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I stn exemM under Sec. ,B&P C for Nis meson BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT.
WORKMAN COMPENSATION DCCLARATION SCHOOLTAX Y N
❑ Thereby afOrm that]haveacenificem of consent to self-insmrc,oacertificate of FIXTURES-PER TRAP RECEIPTN
Warken'Campenmtion lnsumnce or acerlified copy thereof(Sec.3800,Lab CJ which PARK PCC Y N
cuversalle loyees n is nock. _ CAS-EA,SYSTEM-IINC.40U1LETS RECEIP #
Policy p - BUILDING DIVISION FEES
11
Company �A /WA
_ ,. GAS•PA:SY57F.M-OVER4(FA) -vim PLANCIfECK FEE
❑ Gerllfled•-e.p Is arty Is M. �.-
❑ Cenifred copy is filed with Ne city inspection division. GREASEBNDUSTRL WASTE Mqpro Jy GRADWO FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 'G S A ) SOUS FEE
COMPENSATION INSURANCC
Missectionneednmbecompleandif Ne,mat Islas one hundred dol (S ) 5 W 1 O A ) ENERGY FEE
or leas.)
rt
I certify that in Ne performanceof N<wod For which Niepermit is issu ,lei all I A EATER ENT {
am employ any.anon in any manna x es to become subjmt to the orke s" PAID
ZCompensation Lawsof Celifomis. Do.— _ WA'I'F !f' Date Receipt Is
Applicant
0 0 NOTICE,TO APPLICANT:IL after making this Certificate of Haemption,yoahauld NEW RESIDENTIAL PLMB. SQ.,PT.,dr TOTAL:
� En become subject the Worker's Compensation provisions off] Labor Gode,y must ,
a , forthwith comply with such provisions or this permit shall be deemed reBUILDING FEE
i ...
a Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihercby.M.that there iaa construction lending agency for the performance of TOTAL: ELECTRIC FEE
Q the work for which this permit is issued(Sec.3097.Civ.CJ
W. Le
p Lender's Name
>, L) Net PLUMtlING MEt•" nders Address QTY, MECHANICAL PERMIT FEE
I certify than 1 have read this application anN
d state et Ne aboma
starve information is
>, LS7 correct,l agru to comply with all city and county ordinances and state laws relating w PERMIT ISSUANCE MECHANICAL PCE
U z mhbuilding,.monedon,and hereby authonx representntivesoflhisciry tuemerupon the CONSTRUCTION TAX
.ve-mentionedroperly Pfor inspection purpose, ALTER OR ADD TO MEC I.
(We)agree to save,indemnify and kap less the City of Cupertino against
lieldlities,judgments,costs elexpenses which many wayac agimI said City AIR HANDLING UNIT(TO IB,OgO CFM)
ft ing of his
L AIR HANDLING UNIT(OVER 10,010 CFM)
o ¢an r
Eau EXHAUST HOOD(W/DUCD PAID a
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT GG 100.0011 BTU) Date Receipt#
Will the applicant or nature building occupant store m handle hasoodous material HEATING UNIT(OVER IW,ODO BTU) TOTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the I Iu1N and Safety
Code,Section 25532(a)7 VENTILATION FAN(SINGLE REBID) a
❑Yes 11 No
Will the applicamorNmrt buildingoccupant ueeequipment mdevicu whichemit
BOILER-COMP(3HP OR Iffl."BTU) ISSUANCE DATE
haaallom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOLCDO BTU)
DimocR IP
❑Yes El No NEW RESIDENTIAL MEClI. SQ.FT. (iLl
1 have reed the hazardous moenals requiremems under Chapter 6.95 of Ne '��
California Huta&Safety Code.Sections 25505,25533 and 25534.1 understand that ��
if Ne building docs nm curtenrly have a tenon,Nat it is my responsibility w many the
occupant of the requirements which must be met prior to issuance of a Certificate of /yr
Occupancy, �k/a�I r of
Owntt m euthonzed egem Date TOTAL: ISSUED BY:
/ 1
OFFICE