27315 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO emcD27315
iNC-M.F.CrRIFTWE PERMIT No. ^7^ S 5
APPLICATION/PERMIT PLUMBING-MECHANICALLDs
BUILDING DIVISION BUIING PROAWT IDENTIFICATION
BUILDING R� � UNI'I'N LOTp SANITARY NO. APPLICAI1TI�O�}Nk�ISUBMTITAh DATE
OWNER MF' PHONE: CONTRACTOR'S NAM LIC NO: I—• `�
7NICARCIIII'LT/ENGINF.IiR: LICNO: AOORLSS:
CONTACT: - PHONE: ^EC ..
QELP.CTRIC PERMIT PEE BUILDING PERMIT INFO
7Ni{'''- 'X" " -navO, BLDG ELECT PLUMB MECN
PERMIT ISSUANCEEl El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCR ON
gixZ Iherebyaffirm ilia,l sus licemeJ underpmvisiomnfChepser9(commencingwith
POO Section 700(1)of Division 3 of the Business and Professions Coda and my license is in PANELS
full force and effect. UP T020oAMP5
F Z License Class Lic.p I •L
m<y Dom Contractor 201.UXOAMPS
F'O' ARC)IITECTS DECLARATION SQ.FT.FLOOR A $/SQ.F1'.
2 O N 6 OVER 1000 AMPS
O Z�qq I nnJemmoJ my plans shall be used as public records.
ern ly SIGNS ELECTRICAL
G] Licensed Professional
OWNER-BUR.DER DECLARATION SPECIAL CIRCUfgMISC.
XOaU I hereby idffi m that 1 em exempt from the Communes Li n law bathe
�Cacn following mosoe.(Sectlen 7031.5,Business and Professions Code:Any city or county TEMP.METER OR TOLD INST.
t E1 Oy J which requires o permit to mr s eco,shed improve,demolish,or repair any swcture
f�y Y� zvol
prior to its conace,also requires the applicantsfnsuch Permit o signed comment POWER DEVICES
�Withat he is license)pursuoni to the provisions of the Contracmr's License Low(Chapter
a
(commencing with Section 70(M f Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
o Bwi )o ) VA TION
❑y
or h7031:5 by thacfrnmwdthe Permit sbeasegeJexemptin.Anyvienaon of OUTLETS-SWITCHES-FIXTURES
Section a than
by an hundred
cant r,($50nnit subjects the applicant to a civil Penalty of /
C
not more than fve hundred dollars($500). NEWRESIDENTIALELECIR —SQ.FT.
yte m ❑ L aevoricanheestrucgormyempindedorthwegeseathe(Ses.campemsinessTYPE CONSTRUCTION
_ will dothewons C d e:The Cuteis tors License Law doesofficard nota See.7o 44.Business
and Professions Crile:The Contractors License Lew dens nes apply to an owner of
pmpeny who builds or improves themoreand whodwas such workhimselforthrough his CC. UP RES.UNITS
own employees,provided that such improvements me not intended m offered far sole.If,
however,the building or improvement is sold within one yearofcompletlon,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
role.).
❑ I,as ownerof the property,ameaclusivelycontmning withliccvedcoommunam QPY• PLUMBING PERMIT FEE OOD ZONE APN
construct the pmjem(Sec.IDM,Business and Profeadions Code:)The Cmnmcmrs
License Lawdres not apply toanownerefpmperry whobeildsorimproautheraon,and PERMIT ISSUANCE'
whocontmcts for such projects with acontrumodid licensed pursuanUoshe Conuactori ALTER-DRAIN&VENT-WATER(FA)
License Law. FEE SUMMARY
❑ I am exempt under Sec. D&P C for Chir remon BACK FLOW PROTECT.DEVICE OUT915P
SANITARY Y N
Owner Dare RECEIPTp
• a WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, SCHOOLTAX YN
❑ I hembyaffinn that i have acenm
ificamfcove
nnt tose161mme,macenifmmeof RECEIPT
Workers'Compcosation Insurance ora certified copy thaacal'sc.3800,LobCJ which PlX'1'URPS-PF.R TRAP PARK PEE Y N
covers all employee's under this permit. GAS-UA.SYSTEM-]INC. OUTL; _ RECEIPfa
Policy p BUILDING DIVISION FEES
Company GAS-CA.SYSTEM-OVER 4(EA) - PLANCHECK FEE
Cl Cenifed copy is hereby Ibmished.
❑ Certifed<npy is fileA with the ciiy inspection Aivlsioa GRFASIANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOUS FEE
COMPENSATION INSURANCE
(This section need not be completed if the permit is forms,hundred dollars($100) SEWER-SANITARY-STORM EA.200FT. ENERGY IEE
or less.)
Icertify that in Ne performance of the work for which this permit is issued.)shallWATER HEATER W/VE- /ELECfft
not employ any penin any manner sous to become subject to the Workers' pA1D
Compenet ionluwsor Celifomia. Date WATER SYSTEM/TRHATING [)are Rmcipip
z Applicant -
z 0 NOTICE TO APPLICANT:If,after making this Cciificase of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
F U) become subject to Ne Workers Compensation provisions of the labor Crede,you must
forthwith comply with such Provisions or this Amari t shell be domed revoked. BUILDING FEE
0.i Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
=I z l hetebyaffirm that them iso construction leadingagency for the perfmmencemf �.
V O the work for which this Aerie is issued(Sm.3099,Civ.C.) + T ELECTRIC FEE
LI. Plender's Nome s PLUMBING FEE
lenders Address QTY. MECI IANICAL P13RMIT PEE
U I certify that 1 have read this application and state that the above information is
concert.lagramcmmply with all city vW roomy mNinances end atom laws relating to PERMIT ISSUANCE. MECHANICALFEE
I-" � huildingmmtrumion,and hereby in at. naes
0vofthis city mature upon the CONSTRUCTION TAX
U Z above-mentioned pro,my for inspection purposes. ALTER OR ADD TO MECH.
( ve,indent ken h the of Cupcninm against
liabilitics,judg a,cosr peae.w c any m eagainstsaid City AIR HANDLING UNIT(TO BLOOD CFM)
arms" c Oft noil ofdas
AIR HANDLING UNIT(OVRR IQfl00 CFM)
.r nature A iene/Coturaetor Data BXIIAUSTHOOD(WJDUCTI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM.M)[]TO) Data Rmeiptp
Will the applicant or future building occupant state or handle hazardous material
as defend by the Cupertino Municipal Cade,Chapter 9.12,and the Health it Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Section x)'1
❑Yes
0 N
VENTILATION FAN(SINGLE RBSID)
Will the eppl icam ce
or future building cupam use equipment ordevica BOILER-COMP(31IP OR 101),
which emit 01all BTU) ISSUANCE DATE'
•hazardous air contaminants as defined by the Bay Arab Air Quality Management BOILER-COMP(OVER❑ 1(10,000 BTU)
DislrictP PAID
Yes ❑No NEW RESIDENTIAL MCCH. SQ.FT.
I have mad the hazmdmus materials requirements under Chapter,6.95 of the NOV 18
Califomia llealth&Sulkty Code,Sermons 25505,25533 and 25534.I undemuad that
If tbo building docs nun conenlly have a tenant,dot it is my omponsibilay In notify the
occupant of the require renis which must Mand print to issuance of a Certificate of
Occupancy. (`
OwnermituNoriud,gem Data TOTAL: ISSUED BY:
OFFICE