27952 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES^USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELERI AL PERMITNO.
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION - 1 BUILDING PROJECT IDENTIFICATION 27952
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATE
1.01' i/J V J
OWNS 5 AME: PHONE;: UNIT k
CONTRACTOR'S NAME: LTC NO:
_ N/C CONTROL p
•ARCHITECT •
GI ? . LCNO: p DR S:
7 fo 4 cAac
CONACT:TeQ PHONE:a93^y7/7 QTY. ELECTRIC PERMIT 'FEE BUILDING PERMITINFO
BLDG ELECT PLUMBC
PERMIT ISSUANCE �I
LICENSED CONI RACfOR'S DECLARATION APPLIANCES.RESIDENTIAL TOB DESCRIPTION
Ihereby❑(firm that l am
licensed under provisions ofC'hupter 9(commencing with
P00 fation]OBdffDivision]of me Business and Prof<uiona Cade,and my license is in ppNEIS
KiMF�l fullfomeand err
F ZV'Z, License Close 7Q Court �a201.1UPT0WAMPS
y=y pate��I.�Qb GlCT'SaI - ---'`pa 201-IMIOAMPS
ZOyS "h`11' ELTS DE LARATTON OVER ImXI AMPS SQ.PI'.FLOOR AREA 8/5Q.FT.
O Z-5p 1 undersand my plans shell be used as public records.
rn2; SIGNS ELECTRICAL
Q ,� LiantW Professional
CW u OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OdU 1 hereby affiw that 1 am exempt from the Contractors License Law for the
3 stn following reason.(Section 7831.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
E1 y 5 which requires a permit in cormi Wter,improve,demolish,in repair any structure
}�
prior o its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES
Oa that]in is licensed pursuant to the provisions of the Contractor's License Law(Chapter
a eLL 9(commencing with Section,7")af Division 3 of the Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
so or that he is exempt mertfrom and the basis for me alleged exemption.Any violetionoF
F.Za Section 7031.5 by any applicant for a Pewit subjects the applicant to a civil Penalty of OUTLETS-SWITCHES-RXTUR§WTAI.:
H2,[��i7^- not more than five hundred dollars NEW RESIDENTIAL ELECIR
❑ I,usownernfthepmperty,ornryemploymeswim wagesustheireolecompensmion, STORIES TYPECONSTRUCf10
a will do the work,and the swctura is not mondedoraffertd forule(Sm.]044,Business
and Professions Cale:The Convectors License Law does not apply to son owner of
propertywhobuiidsmimproveztherean,and shod.suchwmk himxlformmugh his OCC.GROUP RES.UNITS
nemployees,provided thatsuchimprovements a renotinandedoroffered farsale.IL
however,me building or improvement is sold wiminone year ofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of sale.).
❑ I,mown❑rofineMm ny.emexclusivelycantmctingwimlieensWro ionm QTY. PLUMBING PERMFEE FLOODZONE APN
construa the project(Sec.]844,Business and Professions Cale:)The ContractorsPLRMITISSUANCE
Liccaxc luwdoes imt apply to un ownercfproperty who huilds or improves mcrconandwho convects forsuch projects with acontmchahs)licensed pursuantto the ConvenorsALTER-DRAIN@VENT-WATEuanme lyw. - FEE SUMMARY
❑ I am exempt under Sa. ,B @ P C far this mason BACK FLOW PROTECT.DEVICE IDE FEES
SANITARY Y_N
Owner
Data DRAINS-FLOOR,ROOF.AREA,COND. RECEIPI'it
WORKMAN COMPENSATION DECLARATION ,TAX YN
❑ Ihemby affirm mutlhaveacenificwmofconxnno self-imurt,oraartifiente of FIXTURPS-PPR TRAP RECTA,PT#
Workers'Compemadan lnsumacear a certified copy mercof(SecJ800,Lab C.)which PARK FEE Y N_
covers all empioy9�y tynD hi;g�tygpZA GAS-EA.SYSTEM-ZINC.40UTU?TS BUILDINGp VISION FEES
Policy M �/J �-/ _
Company '^ GAS-EA.SYSTEM-OVERO(FA7 PLANCHECKF E
❑ Certified copy is hereby famished:
RJ CmifiM copy is filW with the city inspection Division. GREASFANDUSTRLWA!7,1K1TIRcEPUOR G DING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRA DEP.
COMPENSA'T'ION INSURANCE
(This secticaneW nm becomplaed ifthe permit is fimme hundreddollers(SIW) SEWER-S NITARY-STORM EA.200py
or less.)
I certify mat in meperfoumulam'due workforwhich mispermit is issued,]shall WATER IIIA RWNENT E
act employ any person in any nummer so as m become subject in the Workers' pplp
Z Compsmation Lsasi fCalifornia. Data WATER SYSTE SATIN Date Remits
O Applicam
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL LMR. SQ, TOTAL:
M become subject to the Worker's Compensation provisions ofthe Labor Code,you muss -
�. forthwith comply with such provisions or this permit Shull be deemed revoked. V BUILDING FEE
W z CONSTRUCTION LENDING AGENCY SEISMIC FEE
^a Ihereby effw mm mere is o conswction lending agency for me perfomm�ce of
me work work for whichmis pe.it is issued(Sec.3097.Civ.C.) TOTAL: ELECTRIC FEE
O Lender's Name ' �, `
[VVr Leader's Address Q7:1',774_'MECFI'ANICAL PERh1I' PLUMBING FEE
FEE
I certify that 1 have read this application and sate that the above information is
correct, l agrm to comply with all city and county ordinances and sate laws rtlwing to PERMIT ISSUANCEMECHANICAL FEE
building construction,and herebyawhorize representatives ofthis city in enter upon the
U 7 above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
C (We)agree m mace,indemnify and keep harmless me City of Cupertino against
Iubilities,judgments,cowsendexpenseawhichmayin any wayacmeagamet said City AIR HANDLING UNIT(TO 18,800 CFM) JA
n comequence of the graining of this pewit.
AIR HANDLING UNIT(OVER 10,0011 CFM)
Signature of ApplimntlConwctor Data EXHAUST GOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CrO I W.00D BTU) Date Receipt a
Will the applicant nr future buildingoccupant store or handle hirmdous material HEATING UNIT(OVP.ft 1013,"BTU) ]'OTAL:
as defined by the Cupertino Municipal Cade,Chapter 9.12,wall ld the Heaand Safety
Cade,Section 25532fa1? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will the applicant or furore huilding occupant use equipment ordevices which emit
BORER-COMP(3HP OR ID%"BTU) WCIAWEDATE
•hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMPG°'a " VER IW.UW BTU)
❑Yes ❑No NEWRPSIDPNTWMCCII.
SQ. T. APR 25
1 have read the hazardous materials requirements under Chapter 6.95 of the rx l�yr ur CU
JL�
California Health @ Safety Code,Sections 25585.25533 and 25534. 1 understand that y 1 r L
ifthebuilding doesnalmomently have aarrant,that it is my responsibility nnotifythe �.
occupant of the tes not
curie which man be th prim m respore of.ility t wrifye of
he
Occult _e_ N� ll9a��4,�Y
Owner to uuthonzed agent paT TOTAL: ISSUED BY:
OFFICE