27999 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' '- -- - PERMIT NO.
APPLICATION/PERMIT PLUM BING-MKDENTIFIC 27999 7 9 9(�
BUILDING DIVISION BUILDING PRUJRC'T IDEN'TIFICAT'ION L J J
BUILDING ADDRESS: SANITARY NO. APPLICA9'ION SUBMITTAL DATE
UNIT# LOT#
04
iRs AME: PxONE:`SORD )Z
R'S NAM :, LI %q —N-ICT ONTROL#
, qsC� ARCHITHLT/EIJ ER: LIC NO: ADDRESS: y ❑
coNTACf: pxOrye: QTY. ELECTRIC PERMIT 7y`i\• FEE BUILDING PERMIT INFO
PERMIT ISSUANCE BLD ELECT PLUMB ME❑CH
LICENSED CONTRACTOR'S DECLARATION APPWANCES-RESIDENTIAL TOB DFSCkIPfION
mwz Ihereby affirm that I am licensed under provisions of Chapter 9(commencing with
X00Section7001bofDivision].(tbeBminesandProfessionsCode,andmylicenseisIn pprygls `` A,oS
V- full force and effect. W\`,/�`a
<- Liceme Class Li,# UP T0100 AMPS
m'y Date Contractor 201-1000 AMPS
zQNZ ARCHITECTS DECLARATION OVER II%10 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0 z_❑ 1 understand my plans shall be used as public records.
P4 ; SIGNS ELECTRICAL
4 Licensed Polecionsl
¢C1'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
x'W' I berehy from that 1 am exempt from the C.n,.cmr's License Law for the
W�p a y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
F-�C'j which requires a permit'.construct,alter,improve,demolish,or repair any structure
KW�;F prior to its issuance,also requirts the applicant for such pemdt to file a signal statement POWER DEVICES
15<0 'bat he is licensed purs.am or the pmvisi.nsof the Contractor's License Law(Chapter
6Ke� 9(commencing with Section 700b)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
ty_m nr that he is exempnherefrom and the basis for the alleged exemption.Any violation of OIpTLETS-SWRCHFS-FlXTURFS
FZY Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty.(
not more than five hundred dollars($5w).
W L-= ❑ I,asownerofthepropmy,ormyemployeeswiNwageswthcUsolecompenaGon, NEW RESIDENTIALELECIR _SQ.FT. STORIES TYPE CONSTRUCTION
a3— will do the w.,k,..d tMstmctum;s not intended moffered f.rsale(Sec.J000,Business
and Professions Coda The Contracmra License law does not apply to an owner of
property wbo builds or improves thaecn,and who does such work himself or through his
oweemployces,provided thesuch improvements aenot intendedoroffered forsee.If. OCC.GROUP R15.—UNITS
however.the building or improvement is sold within one yeaofcompletion,the probateowner- TOTAL:
builder will have the burden.t proving that he did not build or improve for probate of
nk.).
❑ Las.hoprject(Sec.704anesclueiv andcontracting
siosCodc:)n Conowtsm QT PLUMBING ERMIT FEE PLOOD ZONE ApN
icerficonsumer the project(Sec.]000,Businus and Professions Code:)no Convector's
Wconse Lme Mea nm applymanownconf wen)licen punumpr.vesConm,and PERMIT ISSUANCE,
Lice.1�hocontmcu forsuchprnjectswiNacono-acmr(s)Iicenud pursuanuothe C.no-act s AUMR-DRAIN&VENT-WAl'Eft G
Licenm Law. ) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for]b asom BACK FLOW PROTECT.DEVICE OUTSIDE FEF,
Owner Date
SANITARY Y N
DRAI . OOR,R F,AREA. ND. RECElPTp
c WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ IM1creby affirm chart have.cen;ficare.fc.nsem Itself-insu ,oraarOficate of Fl%TU PER TRA RECEIPTp
Workeri COmpenaa;on Insurance or a cost BW copy thereof(Se. 'M Lab C.)wldcn PARK FEE Y N
n all entpl.yce's under this pernil. SYSTEM 1 O EfS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS- .SYST O 0
❑ Codified copy is hereby Tumishcd. � ( PLANCIIECK FEE
❑ CmifieJ copy isfikd with the city inspection divisi. SFy1NDUSTRLWASTE I TERCEPTOR GRADING FEF.
CERTIFTCATEOFE%EMPION MOM W KERS' EASETR P 1 SOILS FEE
COMPENSATION INSURANCE
(This section need nm hecompleted ifilia,mol is for one hu dredd.Ihmrs($I(1)) EWER-SANITARY-STO MEA.200FT. ENERGY FEE
or I
I certify that in Ne performance of Ne work for which this permit 'ssued,lshall ER HEATER W/V /ELECTR
It"'employ any person in any manner an az to become subject m Worker' PAID
Compenmtion Lawsof California. Date WATER SYSTEM/TN ING Dine Receipt#
'z Applicant
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEWRESIDENTIAI. LMB, SQ.FT. TO L:
F' r^�r Ixc.mc subject m tnc W.rkds Compensation provisions of the Labor Cade,you must
fuMwith comply with such proWsi.ns or this pemdt shall be deemed revoked.
(Y � BUILDING FEE
0 z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction lending agency for the performance of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
V.
U Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify In.,I have read this application and state thin the shove infornmi.m is
FOW. comma. I agrec to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
� building construction,and hereby suthodre mIficAmulives ofthis city menter upon the
U z above mentioned property for inspection purposes. ALTERORADDTOMF.CH. CONSTRUCTION TAX
(We)agree to save,indemnify and kap hamless the City of Cupertino against
lixhilities,judgmems,ensu and expenses wh' may in any wayuccme agunstsaid City AIR HANDLING UNIT(TO 10.000 CFM)
;nc of Ne ting of Nis pc ,I
X Y ^Q AIR HANDLING UNIT(OVER 10,000 CFM)
Sngnawm f nplieanVCommaor Dine EXHAUST HOOD(W/DUCT)
PAID
IIAZARDOUS MATERIALS DISCLO RE HEATING UNIT(TO HmF f)BTU) Date Recard it
Will the applicant m future building occupant sore or handle l aourdous nmmdal
as defined by the Cuperlmo Mumnpe Code,amber 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Solicit 25532(a)1
❑Yes 0N VENTILATION PAN(SINGLE RESID) `D
Willtoupplicad,orfuorebuildingoccupanmucquipncriordeviceswhich emit BOILER-COMP(JOE OR I(I0.0D)BTU) IS$ A CEDATE
hr,it as air unmmommts as defined by the Bay Area Air Quality Management BOILER-COME(OVER IWJM BTU)
Llf�effi
PR 28 �g98
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. C//
e mad the buanlo.s materials mymocroems ander Chapter 6.95 or the r ur u(/ptH(IN p
ealth&o,cro Cale,Sections 25505,15533 and 25530,1 ky,,rm if Netnge reenotments yich atenant,thino is mymspnceoila to.eify@e
the rcyuircmenu which meat Ire ma pror to issuance of a Cmificae of
.uthor�agent Date
TOTAL: ISSUED BY:
OFFI