27935 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOnon-eunPERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 27935
BUILDING ADD S: - ^ , SANITARY NO. APPLICATIONSUBMITI'ALDATE
Of I
OW SNAME: I sP11pNE:�JeF
CO RACI'OR'SNAME: LIC NO:
1✓�1� NIC CONTROL a
III •AR /p 1 SER:v LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MF.CH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DFSCRIPI'1py
P4a'Z Thereby affirthat vision an 3 offla,Buinssand onfiesimas Code,and
mmecense with
40 Section a and of Division 3 Of Ne Business end Profession Code,end my license is in PANELS fT�"�llr►�/•/VI�, Tv'^^1 TS/VV.
p OF full force anJ effect.
G Z uIUUI License Class Lic.k UPT0200AMPS
re<a Dae Contractor 201-1000 AMPS
,Z FOy ARCHITECTS DECLARATION OVER IUIXIAMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ-0 1 undersand my plans shah be used n public records.
YSIGNS ELECTRICAL
rnfe
Liccnsul Pssionvl
a' V OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
N, I hereby affirm that 1 am exempt from the Contactors License Law for the
A—
W,, following reason.(Section 7031.5,Business and Pinfessions Code:Any city or county TEMP.METER OR POLE INST.
1.of u, which requires a permit to construct,titer,improve,demolish,car repair any a..
W7 pd.,cut its iesume.,also onmirestheapplic.rrt for such permiuo file.signed suxment POWER DEVICES
yl CLQ 0O that he is licensed pursuant to the provisions of the Contractors License Law(Chapter
e.ta, 9(commencing with Section 7")ofDivision Sof Ne Businessand Profession Cade) SWIMMINGPOOLILEC111C VALUATION .
W'^y omhathe is exempt therefrom and the basis fnr Ne alleged exemption.Any violationnf OUTLETS-SWITCHES-FIXTURES
QSection 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of
n more than five hundred dollua($500).
u:9 n❑ I,nuwneroDheprnpeny,ormyemployeeswith wegnvstheiraolecampensation, NEW RESIDENTTALELECB _SQ.ITT. STORIES TYPECONSTRUCTION
out
will do the work,and the strucmreis not imendedoroffered for sale(Sec.70VI.Business
and Professions Coale:The Convectors License Law does not apply to an owner of
pmperty wholooldsnrimpmvesthe......Oil whodoes uch workhimseiforthr iddi Ms OCG GROUPRES.UNITS
own employees,provided that such improvements are not m¢nded or offered handle.If..
however,the buildingor improvement is sold withinane yeaofcompletion,the owner- 'TOTAL:
hui Wer wil I have the buNen of pruning thus he diJ not buil)or improve for purpose n(
sale.).
❑ I,nownerofthe pmpeny,amexclusively contracting with licensed contractors to QTY' PLUMBING PERMIT FEE FLOODZONE APN
common the project(Sec.701 Business and Professions x mn Code:)The Convector's
LicenLawdoesapply loan ownerofpropedy whobuildsmimprovuthereon,end PERMIT ISSUANCE
whocontractsforsuch pmjmts with aromramods)licensed pursuant to the Contractors pI:fGR-DRAIN&VENT-WA'RiR(EA) FEE SUMMARY
ElIan exempt under Sec. ,B&P C for this reemn BACK FLOW PROTRCT.DEVICE: 5IT'SID EFS
Licenx L.w.
SANITARY Y N
Owner Dae RECEIPT'a
• co WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA.COND. SCHOOLTAX Y N
❑ IherebyuffivntbatlbaveaceniricateofconxnitoxlbRECEIPT#
insum,Oracenificateof FT%TURES-PER TRAP
Workers'Cnmpensadon Insurance or accnifmd copy thereof lSec.7g00,Lnb CJ which PARK FEE Y—N
—
covers all employee's under this permit GAS-EA.SYSTEM.]INC.4 OUTLETS RECEIPT#
Policy a BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifledcopyishemby Podandad.
❑ Cenilied copy is filed with the city inspection Division GRFASEIINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section used not hecompleted ifthe permit is forone hundrMdoll.n(SIM) SEWER-SANITARY-STORM FA.201 ENERGY FEE
less.)
I candy that in the peefomance of the work for which this permit is issued,ishall WATER HiI TER W/VE14T/ELECTR
out employ my person in any mender an as to become aubject m the Wmkeri PAID
Compensution Lawaof Celifomia. Date WATER SYST'EM/1'REATING Data Receipt#
O z Applicant
z O NOTICE'I'0 APPLICANT:If,after meting this Cenifimte of Exemption,you should NEW RESIDENTIAL PL.MB. SQ.FT. TOTAL:
Z? become subject to the Worker's Compensation provisions of the Labor Code,you most
1 fanhwits comply with such provision or this permit shall Is,desmed revoked. BUILDING FEE
W�
:z CONSTRUCTION FEE
CONSTRUCTION LENDING AGENCY
UI hereby affirm that dame is a construction lending agency for the pen'ormance of
Z TOTAL: ELECTRIC FEE
O the work for which this penrdt is issued(Sec.301 Ch.CJ
Lender's Name
0 QTY. MECHANICALPERMIT FEE PLUMBINGVE
tartish Address
W if
1 ccni(y Net 1 have read Nis epplicetion enJ aam that the shove information ix MECHANICAL FF.E
correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE.
F-' U71 buildingcontrvctloo,and hereby authorize reprexnadves of Nis city toemuupon the CONSTRUCTION TAX
U z above-mentioned prnpeny for inspection purpose. ALTERORADDTOMECH.
(We)agree m rove.indemnify and keep handless the City of Cupenin0 against
liubilitiea'udgmenu,costs andexpedseswhich may in any way egainnx Cit AIR HANDLING UNIT TO 10.000 CFM)
m f1h granting.(Nisperm I. �a AIR HANDLING UNIT(OVER 10,000 CFM)
Si p�UC ntmmor Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE• HEATING UNTT(TO 100,031 BTU) Date Receipt If
Will the applicant or fuare building Occupant alma or hurdle hazankma material HEATING UNIT(OVER 100,000 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)
❑Yes ❑No
ISSUANCE DATE
Will the applicamorfumrebuildingtxcupmt uxequipmem ordevices whichemit BOILER-COMP(3HP OR Iffil"BTU)
hazardous air contamimnts es defined by the Bay Am AG Quality Management BOILER-COMP(OVER 100,000 BTU)
• District?
❑Ycs ❑No NEW RP.SIDENTIAL MECH. SQ.FT.
I have read the heandoux materials requirements under Chapter 6.95 of the
California Hi alth&Safety Code,Section 25505,25533 end 25534. I timemmil the
if the building dues nm currently have a nu mu Nut a is my responsibility to notify Ne
occupant of the requirements which must M met prior to issuance of a Certificate of _
Occupancy.
Owner nr umhorized#gem Date TOTAL: ISSUED BY:
OFFICE