27814 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO x aDING-RLECTRI AL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 27814
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION Ii
BUILDING ADDRESS: }1 SANITARY NO. APPLICATION SUUBB�M,;Pl.DATE
O �,,t S UNIT# LOT# �
OWNERS NAME: Pt10NE: CPNIRACTOR'. N ME: LIC NO: ' y
S #� tb^r A NIC CONTROL#
•ARCIII'IEC IENOINEER: - LIC NO: DR S 3 ❑
' o o elle `+
CONTACT: It AV PHONE: QTY. ELECFRIC PERMIT FEE BUILDING PERMIT INFO
Leo a 3 6 S UG 'El El El
PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACT 'S DECLARATION APPLIANCESRESIDENTIALLOB DESCRIPTION
pyZ IherebyuffinmthetlmnliccnsN unJu o ns of Chapter 9(commencing with
POO Stati701n 70Division 3wf tlm Busitim—ad Professions Cwdw,and my license is in PANELS
yUF full forceand cffcfy/
Ea„Zw Lian. Class ` LIGX 613389 UP T0200 AMPS
rn?tai Dam �_��_..4�Convecmr�a„ 201-HI(p AMPS FP-tv
T pN< ARCIIITECTSDE LAA 10 OVER IWO AMPS SQ.FT.FLOOR AREA $/SQ.IT.
O Z-- I andersmnd my plans shall berried as public records.
r Lv L:w SIGNS ELECTRICAL
Qy G_d Licensed Professional
°�Oa'Q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
yU 1 hereby of inns that I nm exempt Ilam the Contractor's License Low I'or the
'13 seri followinTE
g reason. 903 L5,Business and Professions Cade:Any city or county TEMP.MER OR POLE INST.
f�'O_1
which requires a Permit to construct,alter,improve,demolish,or repair any stature
X22 Ind In its issouram;alsorequires the sppOcantfor such permit 1. m
fill.signedstamern POWER DEVICES
m4'OOthat he is licensed pursuant ranonlracmrs the provns of the CLicense Law(Chapter
dkSWIMMING POOL ELECTRIC
e4 9(commencing with Seedon7")Of Division 3 ofthe Businessand Professions Code)
E4
VALUATION
ty_rn within he is exempt herefmnt and the basis fee the alleged exemption.Any violation Of OUTLLTS�SWRCIIES-Fl%TURES
�zT
Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of
�S,Q
nmore than five handled dollars($500).
KCo ❑ l,asownerofthepropcny.orm bees with waesastheirsolecom NEW RESIDENTIALELECTR _SQ.FT.
yemp y g pemmiwn, STORIES TYPF,CONSTRUCI'ION
y3— will do the walk,andthc suucmte isnot intended oroffcred far sid.Sec.70#4.Busincu
and Professions Code:The Contractees License Law does not apply to an owner of
prapeny whobuildsor improves thereon,and whodoessuch work himselfonbrough his
own employees,provided that such improvements are not intendedor ofmax1forsola If, OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofcomplefion,the owner- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
elcJ.
❑ Lxs ownendthe propeny,am exdusivdycanvacning with licemedcontractocsro QTY. PLUMBINGPERMIT FEE FLOOD ZONF, APN
tantrum the former(See.901,Business and Professions Code:)The Contractor:
License tawdwcs not apply noanowncrofpropenywhw builds or improves thereon,and PERMIT ISSUANCE
whommrxces for such projects with aconvanor(s)licensed putsumt to the Contractors
License Law. ALTER DRAIN&VENT-WATER(EAI FEE SUMMARY
❑ I um exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE. OUTSIDE ZEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
ATI
WORKMAN COMPENSATION DECLARON SCHOOL TAX YN_
O c❑ Ihereby affirm than l have a cinircum Ofcoascnn0 self-insum,maccnilienteof FIXTURES P RECEIPT#
Wnrkus'Compensation Insurance Ora crnifed copy thereof(S¢.3800,Lab C.)which PARK FEE Y_N__
Policy pll emPl y_�n�lthiq9
r) I GAS�Eq. STEM-1 INC. OUTLETS RECEIPT#
BUILDING DIVISION FEES
Gnnpany,1}q. _ —��#q_{, CA3A
SYSTEM�OVFR4(B PLANCIIF.CK FEE
❑ Cenlydicnpyishembyfumished.
❑ Crnifiod copy is filed with the city inspection division. GRED , NDUSML WASTE INTER PTOE
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR SEIRAP SOILS PER
COMPENSATION INSURANCE
(This scninn need not be completed ifthe permit is fromm hundred dollars(S100) S ER-SANITARY-STORM FA.20OFT.
Or less.) ENERGY FEE
I cenify than in the perfotmanceofthe work fim.hiell0is permit is issued,I shall ATliIi ItEATF. W/VENT/E;LECTR
net employ any person in any mmmef as us to became subject m the Workers' PAID
z Cwmpenumon Laws of California. Dam WATER
SYS
NO Dane Re iptp
Applicant
z 0 NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should NEW REST ,MR Q. 'TOTAL:
p-+ Tq hccome subject the Worker's Compensation provisions of Labor Code.you or
F� 7 forthwith comply with such provisions or this Permit shall be deemed revoked.
BUI GFEE
0. CONSTRUCTION LENDING AGENCY SEIS IC
Z) Z Ihereby affirm that there is u construction lending agency for the Perform ceof #
U O the work for whieblhls pertain is issued(Sec.301 Civ.C.) TOTAL ELECTRIC FEE
Lender's Name
0 F Crude,Address QTY. ECHANI LPERMI FEE PLUMBING FEE
U I cenify that I have Pad this application and state that the aMme information is
Fmncd. lugrco m comply with all city and county rad, ccs and state lows relnniOn PBRMIT IS, CE MECHANICAL 'EE
Tn building construction,Paid hereby malioize representatives ofthis city turnmrupon the
U z abovc-mentiwned property for impenion purposes. A RORADDTOMECH. CONSTRUCII NTAX
(We)agree In save,indemnify and keep harmless the City of Culamino against
linbilitics,judgnmmns,cos adcapenses9th may in anyway accrue against said City AIR HAND GUNII'(TOIQ )CFM)
nt
-nee of thea nT tg of this pe
3_77_ AIR HANDLING VE 10,MCEM)
rgnamrc of ApplicitarK.Onmen,I Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) me Receipt#
Wi 11 the spelde tarfnturt building Occupant stop or handle hevsrdous material
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100,030 BTU)
Code.Seefion 25532(x)'!
❑Yes ❑No VENTILATION FAN(SINGLE RESID) �-
Will the applicant or(alum building occupant use equipment ordevices which emit
BOILER-COMP(3HP OR 100,000BTU) ISSUANCE DATE
•Disv cal contaminants s all as dereed by thQ
e Bay Area Air mlity Management BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.EI.
Love read the havarJuus memdale rcyuiremcnts under Chapter 6.95 of the
a ilenhh&Safety Code,Sections 255(15,25537 and 25534. IunJemand that p1 rr p
lding does not currently have a tenant,that it is my Psponsibilay to notify the S^ A of Nc rnyuirtmenns which must be ten prior te issuance ofa Cenirate Of
cy. Qno['r uuthonzcd ngenr Dam TOTAL: ISSUED BY: '`avaD
OFFICE 0 1 r Uf- GUrEh//lyu