27197 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINOUILDING.EIIELTRTCM. PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27197(]J
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICA'TION I J I
BUILDING ADDRESS: //77 //�� SANITARY NO. APPLICATION SUBMITTAL DATE:
CCP
L &_ 4 Je0 9-5"7- /YgNIT# a, LOT# /o
OWNIiNS NAMH: -/n PI ZONE: CONTRACT OR'S NAME: /� LIC NO'. ( �l
C LOLL Peep-HCleI f Q C D3SI l� NIC CONTROL#
CHITECT/ENGINEER: LIC NO: ADDRESS: Elc f! Dj L lac finTosle-
CONTACT: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMI9'INFO
n n s-/ BLDG ELECT' PLUMB MECH
lee f'�T CNE �L,O - S� PERMIT ISSUANCE sitF 11 ❑
LICENSED CONTRACT ORS DECLARATION APPLIANCES-RESIDENTIAL
py.Z Ihereby affirm that l am licensed under provisions.fChapoer9(cammencingwith LOB DESCRIPTION
W02 Section 7")of Division 3 of the Business and Professions Cade,and my license is in PANELS
,u u full force and effect.
FZ, Liccmm Class Lia# UP TO 2fp AMPS
sn=y Daae Contmnnr 201-1000 AMPS SQ,FT.FLOOR AREA S/SQ.FT.
ZO,Z ARCHITECTS DECLARATION OVER IBM AMPS Q
OZ-0 I understand my plans shall be used as public records.
P'4 F W SIGNS ELECTRICAL
Qy$j LicenrcJ Professional
z a'Q OWNHR-BUILDER DECLARATION SPECIAL CCUHUMISC.
XOaU IR1 hereby affirm tom I am exempt from the Contractors License Law for the
W 3 a ti following rw. ..(Section 7031.5,Business and Profcsaiom Cade:Any city of county TEMP.MEIFR OR POLE INST.
F C which requires a permit to construct,alter,improve,demolish,or repair any structum
' m its couanee,.N.ry thea licum intact no file aslmed,odement POWER DEVICES
poor gmrcs pp perms g
m C O0z that he is licensed pumuanno the Provisions of the Contractees License Law(Chapter SWIMMING POOL ELECTRIC 6KCLL 9(cnmmencing with Section 7")of Division 3 of the Business and Professions Code) VALUJW9l
—,� or tom he is exempt therefrom and the basis fanhe alleged cncmontncivil Areonof
amteOUTLETS-SWITCHES-FIXTURES
�ZaSection 7031.5 by any applicant for a permit subjects the applicilp penalty of
not more than five hundred dollars(SSW).
� 0o ❑ I,as.wnmofthepropeny,ormyemployeeswithwegcssstheirsolec=Nmalion, NEW RESIDENTIAL ELECI'R SQ.FT. STORIES 'TYPECONSTRUCIION
i3= will do the work,and the structure is not incridedoroffered foraile(See.70pu4.Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or impmvo thereon,and who does such work himself or through his
employecs,ptovided that.such improvements are not intended oroffered forsale.If, OCC.GROUT' RES.UNITS
however,the buildingor improvement is sold within one yearofeumpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ I,sowner of lha pmpeny,.mcxdusivdymntracting withlicensed convaemrs to QTY. PLUMBING PERMIT PEE FLOOD ZONE. APN
construct the project(See.7044,Business and Professions Code:)The Contractor's
License Law docsnm apply to anownefo(propeny who builds or improves therson,and PERMIT ISSUANCE
wh.commets forsuch projects with ate sntractor(s)licensed pursuantmdte Contmemra
License Law. ALTER-DRAIN&VES-WATER(EA) FEE SUMMARY
❑ I um exempt under Site ,11&P C for this reason BACK FLOW PROTECT.DEVICE I 1 SIDE FAA
SANITARY Y N
Owner Data RECEIPT p
DRAINS-FLOOR.R ,AREA,CON .
WORKMAN COMPENSATION cdcoment DECLARATION SCHOOLTAX Y N
1 sm CmipersaI hereby affirm shosamnce-at I have a igcateof copythtacif(Sesure,o.Lah C.)which FI%'I'ORES-PER'I'R ft[CEIPT#
aks01e employees
ad this .i,. ificd copy lhuwfl5er.3800,fah CJ which PARK FEE Y N
covers allempl.yu's under this permit. GAS-EA.SVS C.4 S RF,
CEIPTO
Policy N BUILDING DIVISION
IL[S
Company GAS-EA.S -OVER 4`F PLANCHECK FEE 6 ,
❑ Certified copy is hereby furnished.
❑ Ccnilied copy is filed with the city inspection division. OIREASNOISTRL :INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' •TRAP SOILS FEE
COMPENSATION INSURANCE
('HuMuction need oat he completed rthe pc.I,is feature hundred dollars(SIM) SEW1iR NITARV-STORM EA.20s ENERGY PER
orless.)
I ccnify that in the performance of Ne work for which this permit is issued,I"I WATER HATER wovENTiELECTR
not employ any person in any nommo so as to become subject t.the Warkers' PAID
Compensationlaws.f California, Data WATER SYSTEMiTREATING Date Receipt#
O z Applicant
Z0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
become subject to the Wmkaes Compensation provisions of the labor Cade,you most
aforthwith comply with such Provisions or this permit shall rte teemed revoked. BUILDING FEC BO
a (� CONSTRUCTION LENDING AGENCY SEISMIC FEE 1�
7 z I hereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FTE
U O the work for woicn flus permit is issued(Sec.3097,Civ.C.)
Lender's Name
u-' F lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING PER
U I ccnify can 1 have read this application send state that the above information is MECHANICAL FEE Ul correct.l agree to comply with all city and county ordinance and state laws relating to PERMIT ISSUANCE
f— �• bulldingconstruction.and hereby autbode<representatives ofmis city mender upon the
U Z above-mentioned rt for inspection ALTER OR ADD TO MECH. CONSTRUCTION TAX
{rape Y Pec purposes.
(We)agree in save,indemnify and keep may in
the Ciacco Cupenino against
liabilities,judgments,costs andenpenses which may in any weyeccrve against said City AIR HANDLING UNIT(TO 111,0(1()CFM)
in cor.acquence of the granting of this permit.
,- eJ`Azelw. /A/'y�� AIR HANDLING UNIT(OVER 10.000 CFM)
/ /)Il/•.1cJ
f/o
Signmum of Applitvm/C.ntrrcl.r Ilam EXHAUST HOOD(W/DUCI')
PAID /
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(70100,000 BTU) Dom Receipt Is
Willthe applicant.,future building occupumstare or handle hazallous material HGTING UNIT(OVER 100,1100 RTU) TOTAL:
as defired by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CMc,Section 25532(a)'1 VENTILATION FAN(SINGLERESID)
❑Yes ❑No
BOILER-COMP(3HP OR 10,000 BTU) n IAUAtYCEDATE
Will theapplicantorfumrebailding.ecuprot aseequipmentordevices which emit tl W 1 IJ
.Nous air contaminants as defined by the[Jay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU)
ni>via'1 [I251994
Yes ❑No NEW RESIDENTIAL MECH. SQ.IT. OCT 1
I have read the hamrd.us materials requirements under Chapter 6.95 of the I
California Health&Safety Code,Sections 25505,25533 anti 25534. 1 understand that CIIT Vf- Nwmm 1114U
if the building draw not currently have a tenant,that it is my mspansibility to notify the
occupam of the requircmcnts which must be met on,t.issuance of a Cenificme of
Occupancy.
Owneror umhomed.gnat Dole 9'OTAL: ISSUED HY:
OFFICE