27284 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO "UH.Vi, 1,1 Ec1 RIA PERM)PNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. A O
IIUII.DINGI'ROJECTIDF.NTIFICATI()N G o
BUILDING ADDRESS
'� IT
/� SANITARY NO. APPLICATONSUBMTALDA)T
(�V C l_ LOT �.
O ERS ME: CPHONE: O ACTOR'SNAMI?: LIC NO:
16
�5 /'4 C
S&��NQ g /� NIC CONTROL
RCHI'IECf/ENGINEER: LIC NO: ADDRES �C ❑
7111 l e F✓ l Sv"AIY VA 6-
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ' PLUMB MECH
� ECL
PERMITISSUANCE �a ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �S 11B ft
1]mZ I herebyalfirn that am licrnudunderprovisiowofCTaper9(commrndngwith 1
=s1CC Section]1wx1.f5Divis on3 of the Business and Professions Code,and my license is in PANELS
F Z{❑❑❑� fullnse Clad effect. r UPT0200AMPS
ly License Clusa Lic.N
w=y Date Caroni I 201-HiM AMPS 5 IT.FLOOR AREA $/SQ.FI'.
Z.C,z ARC111TIiCT'S DGCLARATION OVER 1000 AMPS
Q
C Z—n I understood my plans shall be used as public records.
Q �W SIGNS ELECTRICAL
y�"...24I Llcemed Professional
c:�K6 OWNER-BUILDER DECLARATION SPECIALCIRCUITIMISC.
LxOyF I hereby affirm that I sum exempt from the Contracmr's License Low for the
W Say folluwiroi emnn.(Section]031.5.Businesimd Professions Code:Any city or county TEMP.METER OR FOUR(NST.
fJ C a which requires a permit to construct,alter,improve,demolish,or repair my suunurt
rn 2to its i.mana,rik. thea licmt for such into flee si ediammord POWER DEVICES 01
prior requires Pp p gn
e. 9(comthat be is licensedp Sectiomom tot )oftssision the Commcmr'sand nsePro Law(Chapter
o. � 9(commencing with genion]OW)of Divisim3of the Businesxand Profcssior Code) SWIMMING POOL ELECTRIC VALUATION
radon beisexem t thexfromandthebasis for the alleged exemption.An violation f
_y p g pion, yvioeiono
�ZQ Scainn]f131.56yanyapplic�ntforupermitsubjectstheapplicammacivilpenahyof OUTLLTS-SWITCHES-FIXTURES
�
not atom than five hundred dollars($5110)❑ .
NEW RESIDENTIAL F.LECIR _SQ.FT. IES TYPECONSTRUCTION
mm pec ❑ Lwowncroftbepmpcny,a is not makdwithwed for sale
y�_ will dothe Code:
structure Com is not License
Law does of apply in sat,Business
and Professions GM<:The Cnnuactors Licens<Law dao not apply to an owner of
property who buildsofimproves NereoLund whudoessrsh wakhirselforthruish his G OUP RES.UNITS
own employees,provided that such improvements are not intended or offered forsake.If,
however,the buildingor improvement is sold within one yearofeampletion,theowner. ^�
builder will have the burden of proving that he did tet build or improve for purpose of
sale.).
❑ I,wownerafthe property,amexclusively contacting wits licensed cormmwamtu QTY, PLUMBING PERMIT FEE FLOOD ZO APN
construct the project(See.7M4,Business and Pscfeaims Code)The Contmeer's
License Lawdoes not apply wanownerofpropeny who huilds mimprovesmercon,und PERMIT ISSUANCE
whocnrracty fmrsuch pmlects with acontractorts)licensed pursuant o the Contractor's
License law ALTER-DRAIN&VENT-WATER GEA) FEE SUMMARY
❑ I tet exempt under gee. ,B&P C for this reran DO I DI.M
BACK FLOW PROTECT.DEVICE.
SANITARY Y N
Owner Dam RECEIPT
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ ers Coyaffmon Insurance
ns rancve a eora certificate urnot to copy
thereof(Seeuw,oraan.)which Fl%TURFS-PER TRAP RECEIPT#
WakenCamprnxtionle,flus eranit, ifird copy thereof(See.3g00.Lab C.)which PARK FEE Y N
covets ell employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
'�m Policy M BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Canifiedeopyisherebyfumishd.
❑ Cenified copy is filed with the city inspection division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Possenimmednm becompleted ifthe permit is Forane hundred dollars($100) SEWER-SANITARY-STORM EA.200P`U ENERGY FEE
or less.)
I cenify that in the pednmeoce of the work for which this permit is issued,l soli WATER HEATER WIVENT/F.LECIt
not employ my person in my manner w w to become subject to the Wisdom' PAID
Compenaationlnwsof Califoria. Dow WATER SYSTEMIRF.ATING Dale Receipt#
O Z Applicant
C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
FU) become subject to the Workers Compensation provisions of the Labor Code,you must BUILDIN011E
� ; forthwith comply with such provisions or this permit shall be deemed revoked.
W �"•'
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 herehy affirm that them is a cmmetructim lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC MElender's Name PLUMBING FEE
4. F Lender's Address QTY. MECHANICAL PERMIT FEE
1 cenify that I have read this application and state that tse above information is MECHANICAL FEE
>., correct, l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
building construction,and hereby amortize representatives ofthis city teenmrupon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify roti kap ImrrNese toe City of Cupenim against
liabillties,judgmems,costs and expenseswhich may in my way accrue against said City AIR HANDLING UNIT(T010,000 CFM)
consequence of the granting of this permit
AIR IIANDLINGUNIT(OVER IO,IXpCFM)
Signawrt of Applicant(Commnor Datel EXHAUST HOOD OVIDUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO DOE."BTU) Date Receipt#
Will the applicant or future building occupant some or handle hazardous material HEATING UNIT(OVER I W,tNNI BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
tZ
❑Yes El No
ISSUANCE DATE
Will the upplicmtorfuture mildingoccupmt aseequipmenmrdevias which emit BOILER-COME(3HP OR 100,"BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COME(OVER tffl, 0BTU)
Distinct?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of tse SOV 14 1994
California Health&Safety Code.Sections 25505,25533 and 25534.I mdemtund that
if the building does not currently have a tenant,that it is my responsibilityto notify the
occupant of the requirements which must be met prior to issuance of a Cer ifcate of CI I Y Ur yyf• •p
Occupancy.
Owner or autsonzcd agent Date TOTAL: ISSUED BY:
OFFICE