27050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO m-l.lDisri-aells,'RIZ1' PBRMrr No. �rY
APPLICATION/PERMIT PLUMB ING-MECHANIC A1,I'I27050
O
WILDING DIVISION BUILDING PROJECTIDENTIFICAON
BUILDING ADDRESS: //�/\�� SANITARY NO. APPLICATIO///NSSSUBMITIFALDATI
Or4r UNIT# LOT#
OW SN W � e PITO ONTRA R' AME: WJ
_ J N/C CON OL
•ARCIBIRCI" GIBBER: LICN : ADORE, i../ ❑
coNl'nc- a Peorve: QTY. ELECTRIC PERMIT I\!9�• FEE BUILDING PERMIT INFO
' BLDG ELEC PLUMB MECH
PERMIT ISSUANCE ❑
LICENS DCONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
=MZ Iherebyuffirmthatl nlicenud underpovisians of Chapter9(cammencingwith JOB DESCRWI[ON
WOO Scotian 7000) ED Sof the Busineaa and Prorcaaio Code.endmylicenseism PANELS
�U� full force and eff crypt
"on , 1(✓\
LQZw 1.imnsc Class Lic.# UPT02MAMN
Nin Date Conunnm 201-EX)DAMPS
ZOy= ARCHRECTS DECLAR OVER Hgad AMPS E/SQ.FT.
O Z—o I underrour y plans.ball be used as public records.
F.,vs F w SIGNS ELECTRICAL
QL5, L.icensal Professional
W,W< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. `
Ec p u I hereby affirm that I om exempt from the Central License Law for the
W 3u. following reason.(Section 7031.5,Business and Professions Code:Any city car county TEMP.METER OR POLE INST.
t�i O¢ which require,a permit to construct,alter,improve,demolish,m repair any structure
CWS prior it) mi
its issuance,also requires the applicant for such pert to file a signed stteremem POWER DIiVICES
W C<C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aaa�' 9(commcncing with SCc11ou 7000)ofDwision 3afthe Business and Pofeuions Code) SWIMMING POOL ELECTRIC VALUATION
,:2o, or that he is exempt herefrom and Ne basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F Z� Section 7831.5 by my applicant for a permit subjects the applicant o a civil penalty of
E S�= not more them five hundred dollars($500). NEW RGSIDLNTIAL ELECIA SQ.FT.
IYFC ❑ I,mnwnerofNepopeny,mmyemployaswithwagesastheirsolecompensation, STORIES TYPE CONSTRUCTION
y3 e_ will do the work.and the structure is not intendedorefend forsale(See.7(#4,Business
and Professions Code:The Cmntmemrs License Law docs not apply to an owner of
popcny vAo builcis cr improves therm n,and wha does such work himeelfor through his
wnemp]oyas.provided that suchimpovemrnts small intended oroffeted fm see.If, OCG GROUP RES.UNITS
however,the buildingler improvement is sold within one yearofcompletion,themmer- TOTAL:
will have the burden of proving that he did not build or improve for purpose of
sole.),
❑ I,as ownerofthe propery,sum exclusively contracting with licensed contractors to QTY. PLUMBING PERMIT FEE P1.ODD ZONIi APN
instruct the project(Sec.7044,Business and Prof—iom GMc:)*Me Conoomrs
I Lienee Law does not apply to anownerofprropcny who builds orimproves derreca,and PERMIT ISSUANCE
who contracts for such projects with acontmctor(s)licensed pursuant no the Contractor's ALTER ( )
License Law. WATER EA FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE, OUTSIDE FE
SANITARY Y N
Owner Dat° DRAINS-FLOOR,ROOF ,CO RECEIPT.
• WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
1 hereby affirm that I have a certificate of coventto self-insure,or a certificate of RECEIPT p
mkcri Cmm tion ns FIXTURES-PER AP
p_ - c:yrecerlj{pQ cnpv thcrtof(Sec PARK FEE RECF.IPfN N
rses &WED" lace GAS-EA.S M-I INQ4011TLET5
Policy a BUILDING DIVISION FEES
Company .� GAS .SYSTEM OVER ) PLANCHECK FEE
[Ifed copy is hereby famished.
Ccnified copy is filed withthe city inspection division. A59EASEMINDUSTR NTER GRADING FEB
CERIIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP. SOILS PEE
COMPENSATION INSURANCE
('Thistle lion need am be completed ifthe permit is for one hundred dollar(SIM) ' WER-SAN] -STOR OUFT. ENERGY FEE
or Icss.)
I cmily that in the Faformmre of the work for which this permit is issued,l shall WA r Wry T CTR
not employ any Foram in any manner so as to become subject to the Workers' PAID
zCater,mmitalawsuf Califomta. Dote WATF. BEATING
Applicant 0.ceeipt#
Q
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,You should NF.WRESI - PLMB. SQ.FT. TOTAL:
F' V] becmmcsubjanolbe Workers Compensation provisions ofthe Labor Code,you must
> foMwith comply with such provisions or this permit shall be deemed rivalled. jELE�C
E
CD CONSTRUCTION LENDING AGENCY
z 1 hereby effmn that there is a construction lending agency for the performance of
U 0 the work for which this permit is isoW(Sec.3077,Civ.C.) TOTAL:Lenders Name
O ULenders Address QTY. MECHANICAL PERMIT IEE EE1 certiftin 1 have rail Nis application and state that tiro above information Is
Carrell, I tgree nt comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE / FEEbuilding corolowhan.and herebyauthorize representatives of this city mender upon theV Z move-mcmlncd r0 dyfor inThoopurpousALTER OR ADD TO MECH. N'TAX
(W gr ,indemnify and keep harmless the City of Cupertino against
liabiliti ,j d, iscosts and expenses which may in any way ace rvea I dCiry AIR HANDLINGUNIT(TO 10,"CFM)
in<an yu mntingafthia it.
/O AIR HANDLING UNIT(OVER 18,110E CFM)
Signaturt of Applicmt/Cmeractm am EXHAUST HOOD(W/DUCp
PAID
IIAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,880 BTU) / Data Receipt#
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cu.min s Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) L:
Code.Section 25532m)7
❑Yes 0 N VENTILATION FAN(SINGLE RESIDE
Will theucamera en,as building by the lay Am Amir orality whicM1emit
BOIIJ R-COMP(3HP OR 100.0co lifu) ISSUANCE DATE
locand. Domir uv air amwminants as defined 6Y the Bay Arcu Air Quality Management BOILER-COMP(OVER 100.000 BTU)
UI.Wm7
❑Yes ❑No NEW RESIDENTIAL.MECH. SGFL
1 have read the M1vardous materials requirements under Cheplm 6.95 of the � IT 18 1994
Califamia I lahh&SuPory Coda Ballon.35505.25577 emJ 255]4. 1 understand Nat
ifthe building does not currently have a tenam.that it is my respmisibility to notify the I. _
curynt of the rtquimmencs which must od met Adm to issumu of a Cenifiao of LU' o s ss;V
Occupancy.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE