27409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
"TAiNGINEEWLICNO:
PERTINO 'IRAU-LE PERMITNG.
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 7II O(�
UUILOINGPROdECI'IDF;N'r1FICA'OON' r 4 J
BUILDING ADDRESS: /,1I/ f/'{/'—/ //'/�/(/�' SANITARY NO. APPLICATION SUBMITTAL OXIE
/ �/ l-/ I / f��(/\ UNIT# LOT#—
PI NE ON'IOTORSN Mr: N' VVV y /C CONTN #
NEIiIi: IAC NO: A r/ ❑ ✓ ��
73
CONTACT: PHONE:
David N � a - /-7 QTY ELECTRIC PERMIT PEG BUILECT PEH IT INFO
BLDG ELECT PL IMtl Mf:CH
PERMITISSUANCE El El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
CIZZ I herebyaffirm that l an licensed under provisionsofCliapter9(comandaing with LOB DESCRIPTION
140f0�. Seedon?000)ol'Division 3 of Om Business and Prnfcssio Code,and my license is in PANELS
aVO3 full force and
F
ZR! License Class ie.p Up T020OAMP5
m?y Date Convector 201-1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z0Nc ARCHITECTS DECLARATION OVER IODO AMPS
0Z_O I und,rsmnd my plans shall Ix used as public records.
C-mFm I SIGNS ELECTRICAL
6—Ej Licensed professional
K Yoa6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oe. 1 hereby affirm tout I am exempt tram the Commemea License law for the
w 31+-y following ra wn.(Section 7031.5.Business atm Professions Code:Any city car county TEMP.METER OR POLE INST.
Ow J which requires a permit to consumer.slier,improve,demolish,or repair any structurt
prior to its issuance,also requires the applicant for such permit to file a signed comment POWER DEVICES
T�y.Q that he is licensed pumuantto the Provisions of the Contractors License law(Cha ger
o. VA WATION
'
M0 WG POOL ELECTRIC
a o4 9(conmomeng with Section Rl00)of Division 3 ofthe Business and Professions Code)
SWIMMING
or that he is exempt hcrclrom and the hnsis for toe alleged exemption.Any violation of OUTLETS-gWITCHPS-F1%TURL9
5F.•Z Q Sation 7031.5 by any applicant for a permit subjects the applicau
no a civil perulry of
�O not.,no than five handled dollars(X500). NEW RESIDENTIAL ELECTR _SQ.PT. STORIES TYPE GGN$'IRDCTIDN
�pw [1I.as owner nfthe property,or my employees with wages as their sole compensation,
M3. will do the work,and the smaa.e is not intended or offered for sale(Sec.9044,Business
and Professions Cade:The Comraaors License Law does not apply to an owner of
property whobuildsodmproves lheram.and who docs such work hlmselfirthrough his OCC.GROUP RES.UNITS
ownemployces.parevided thansuchimpmvementsare not imendedoroffered forsdc.If,
however,the buildingor impowemem is sold within one yearofcompiction,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpese of
sale.). QTY. PLUMBING PERMIT FEE
❑ Las owneroltbe pmpeny,un exdusivdy,onvacting with littnud wntrvnorsm ROOD ZONE APN
construct the project(Sec.9044,Business and Professions Cade)The Convenor's
License Law does not apply Loan ownerefpropeny whubuildsorimprovesthcrwn,and PERMIT ISSUANCE
who contacts for such pmjeco with a cormorants)licensed pursuanrothe Contractors 'fER- &VENT WATER- FA
Licence Law. pLDRAIN ( ) FEE SUMMARY
❑ I am exempt under Sec. .B&PC for this mason OUTSIDE M;ES
BACK ROW PROTECT.DEVICE SANITARY Y N
Owner Data DRAWS-FLOOR,ROOF.ARF,A,COND. RECEIPT If
WORKMAN COMPENSATION DECLARATION S OOL TA% YN
❑ Thereby officer that l have acertificmcofmnsent to self-insure,oracenificaleof FIXTURES-PER TRAP RECEIPT#
Workers'Compo sm ion Insurance or a anlfied copy thereof(Sec.3800.Lab C.)which PARK E Y N
cn all plo a nd Mi t _ GAS-G.SYSTEM-I INC.4 OUTLETS - RDIVISION
Policy# BUILDING DIVISION LEES
CompsnY GAS-EA.SYSTEM-OVER 4(EA) PLANCHFCK 'EE
❑ ComfiWcopy is erebyfled.
El Certified copy is filed wilt a cityinspecdon division. GREASF/INDUSTRL WASTE,INTERCEPTOR GRADING FEE
CERTIIgCATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed iftoe permit is forome hundred dollars SIDE) SEWER-SANITARY-STORM EA.2007f. ERGY FEF.
orless.)
I cenify,that in the Performance ofrhe work for which this permit is issued,i shall 11 WATERHEATERWIVENTIELECIR
out employ any perwn in any manner so as to become subject to the Workers D
CompensarioOLawsof California. Date WATER SYSTEMMEATING Receipt#
ZZ Applicant
NOTICE TO APPLICANT:If,after making this Cmificme of Exemption you should NEW RESIDENTIAL ELME. SQ. TOTAL:
(;n become subject to the Worker's Compensation provisions of Ne Labor Cade,you must
R' 7 forthwith comply with such provisions or this Permit shall be deemed revoked. BU GFF
D.1 n' ' ISMIC pE
a Q CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a convection lending agency for the performance of
U Z TOTAL: ELECT1tI EE
0 the work for which this permit is issued(Sec 71199.Civ.CJ
Lender's Name
F Lender.neareaa QTY. MECHANICAL PERMIT F PLUM rvG FEF. _
O U 1 coldly that I have read this application and state that the above information is ME ANICAL IEE
corm<t, lagraus comply with all city and county odinenms andsate laws alatingto PERMIT ISSUANCE
F-' building convection.and hereby auNoda representatives ofthis city reenter upon the NSTRUCDON TAX
U Z mxnamentloned property for inspection purpnxes. ALTER OR ADD TO MECIL
(We)agree ,e,indemnify it kap harmless the City of Cupertino against
..
,no 11
Gyics,ju prlfeytfc,,..d e,N any way seem,age d...ssj�d sCity IR HANDLING UNIT(TO IOJCE CFM)
f AIR HANDLING UNLT(OVER 101100 CFM)
fN s cont/Cnnwmnr (/Dare EXHAUST I IOODOVMUCI)
.igna um PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt
Will doe ro
applicant or fure building occupant store or handle hazardous material HEATING UNIT(OVER (In"Ii'1'U) TOTAL:
ses defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(0)? VENTILATION PAN(SINGLE RESID)
Cl Yes ❑ No
BOILER-COMP(311P OR 100,1X10 BTU) I$$UANCa DATE
Will the aporantamas is building by the ay Arequiea
Quality
Management
non��- ��SS
L hurallous air nmuminame ns defined by the Ray Arcu Air Qmlity Managcmem
BOILER-COMP(OVER IIXI,g10 B'fU) AR
❑Yes 0 N NEW RESIDENTIAL MECiI. SQ.FT. IKJ �n
I have mad the hazardous materials r,uirtmenb under Chapter 6.95 of the Ly- 95
Califmnisllculth&Safsty Crme,Sections25505,25573and25534. 1understand Nm (q,,- Av
Ifthebuildingdosnotments lyhaveoicon,thato ismy rea3pnslof. tonotifythe CN/yl
occupant of rM1e requirements which most be ren prim to issuance of a Cenificme of
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE
I`