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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUIL'I No-ELECTRICAL, PERMIT NO.
APPLICATION/PERMIT PLOMIIING-MECHANICAL BUILDING DIVISIONIIUILDING PROJECT IDEN'TIFICA"TION
BUILDING ADDRESS: n SANITARY NO. AR'LICNIONSUBMTITAVA
UNIT# LOT
V I�
OWNERS NAME: N PI IONE `IS-2
CONTRACI'OR:S E:OR' NO: N/C CON9'ROLp
yt_f
RCHITECf/ENGINEER: •fA�J LIC NO: GS
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CONTACT: 'Y1l PHONE: QTY. ELECTRIC FEE BUILDING PERMIT INFO
5M J ��` �fy� U PERMIT ISSUANCE D pX PLUMB MEGA
LIC1-LASED CONTRACTOR'S DECLARATION APPLIANCES fqEADEqir1AL
❑KZ Ihend tiffirmthat lmm licensed under provislarm'CTaher9(commencingwith LOB DESCRIYI' N
1^00 Section of Division 3 of the Business and Professions Code,and my license is in PANELS ^
WF. full for c1 1effect. +J
�j❑UU License Class Lick U '1' 2 AMPS
'u,i4d Dale Connie AMPS
ZOO� 1 MP SQ.FT.IT REA S/SQ.FT.
y= ARCHITECedas DECLARATION
O'L ❑ I understand my plans shall be used as public records.
41�
Fy�w IGNS 1:1 RI YY
Q,j F„'Jj Licensed Prol'e,mi,il
C
d'Q
OWNER-BUILDER DECLARATION SPECIAL IR -,MISC.
XO W, 1 hereby n.Sc that I am exempt from the Contractors Urease Law fou the
F4ty following rtasoa(SenionJOJLS.Business mud Profasiom Code:Any city or county TEMP.MEYV OR POLE INST.
which requires a Permit m construct,altar,improve,demolish,or repair any structure
$'^y� m its issuance,also then Meant for such un file a signed statement POWER DEVICES
ttrri� poor requires pp pcmti 1,
aC¢ that he is licensed pursunno the provisions of lbe Contractor,License Love
d d❑ SWIMMING POOL ELECnTRIC VALUATION
e
9(commencing with Saction700()af Division 3ofthe Business and sio
Profesns Code)
W^,, or he is exempt herefrom and the basis for the alleged exemption.Any violation of UTLEI'R-SWITCHES-FIXTURES 26 ��
❑
F•Z Q Section 7031.5 by any applicant for a pmmitsubjects the applicant to a civil Penalty o J
not more than five hundred dollars(5500).
$$� Q.
WCF,�
a ❑ I,asownerofthe prnpeny,ormyemployees with wngcsmnsNEW RESIDENTIAL ELF,CTR lheirsnlecompeedoo. S Q FT. STORIIi. TYPE CONS'TRUCf10N
W will do the work.and lire structure is not intended moffered for sale(Sec.9(144,Business
and Professions Cad¢The Contmnnr's Littn.ae Law docs not apply to an owner of
property whobtildsor improvesihemon,and whodmssuchwork himselforthrough his OCC.GROUP RES.UNITS
wnemployees.pmvided that such Improvementsa snot intendedorafferN forade.If,
however,the building or improvement is add within one year of completion,the owner-
builder will have the burden of proving that he did nal build or improve for pur,soc of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN[II,uownerafthepmp ay,=exclusivelycomractingwiNlicensedconimemrsm
omtmc.the project(See.7044.Business and Professions code:)The Contractors
License Lawdosnot apply m an owmentfpropeny whobuildsoroupt thereon,and PERMIT ISSUANCE
whecntnracts for such projects with a nmructnr(s)licensed pursmntm the Commmor's
Iiwmcl w ALTER-DRAIN&VENT-WATER(EAI FEE SUMMARY
❑ 1 am exempt under lice. ,H&P C for this mason BACK ROW PROTECT.DEVICE T11D1.11.1,1
SANITARY Y N
Owner Dec DRAINS-FLOOR,ROOF.AREA.COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
Y _i RECEIPT a
❑ Iherthynffirm thelbmvn r.,efcatcodeepentmxl(Sec.r800,Lmtifeatich Fl%TURES-PER TRAP
Wnrkorx'Cnmpcnsulion lnmmnccoraccnificd copy therutf(Scc.38W,l.ah CJ which PARK FEE YN
rs all emplayce's undcnhis fKRnil. GAS-HA.SYSTEM-I INC.O OUTLETS REI
Policy X BUILDING DIVISION EELS
y ,ry A�g, GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cenifed copy is hereby famished.
Certified copy is fled with thecity inspection division. 9 EA. 1S W Ii E Cf." R GRADING FEE F6
CERTIFICATE OF EXEMPTION FROM WORKERS' GREAS,TRAPe� �. SOILS FEE D ��
COMPENSATION INSURANCE
This section need not be completed ifthc permit is forone hundred dollaa(SIM) SEWER 5 EA. ENERGY FEE �I
or ossa.) 41 ;win
Iwn ify that in the Pcrunrene oflhe work for which this Permit k oared,l shall WATERIIP F wrfd
mol employ any person in any manner so as to bee nm subject m the Workers PAID
Compensation Lawsof Celifomia. Date WATER SYSTEM/IREATING Date Receipt#
zz Applicant
O NOTICEII'0 APPLICANI':If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL:
t--. become subject to the Workers Compensation provisions of the Labor Code,you most
> forthwith comply wilh such provision nr this permm
asholl be deemed revoked BUILDINGFEE
4 ❑ CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that is a eansruction lending agency for rite performance of
Z L: ELECTRIC FEE
U O the work fee which this permit is issued(See3097.Civ.C.)
PUnder',Name PLUMBING FEE
P Under's Address QTY. MECHANICAL PERMIT FGIi
L) 1 eenify that I have read this application and see shot the at information isMECHANICAL PCIi
correct.l agree to Comply with all city and county ordinances sod state laws reladng to PERMIT ISSUANCE
I-' buddingmnxruction,and hereby authorise representatives ofthis city mentor upon ate CONSTRUCTION TAX
V ,Z above-mentioned property for inspection purposes. TER OR ADD TO M1IF.CII. ��
(We).agree to save,iMcmnify and keep harmless the City of Cupertino against
liabilities,judgmen4enstsmdex,ore,,which may inany wayacerue aguin.al said City AIR HANDLING UNI'((-I'O to,000 CPM)
in consequence of the graming of this pmanit.
r � AIR HANDLING UNIT(OVER 10.010 CPM)
Zrgnmurc of r mraztor Date I EXHAUST HOOD(W/DUCn PAID
HAZARDOUS MATERIALS DISCLOSURE IIEK,N,UNI'T( O Pat(Sit BTU) 1)in, ft
p
Will HEATING UNIT(OVER 100.000 BTU)
as&r,.W by the Cupertino Municipal Cod,Chapter 9.12,and the Hmlth and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will lhcepplir nlorl'ututcbuildinga cupum usce ulpmem ordavic swhi<hemil MOILER-COMP(3HP OR 100,00OBTU)
haistdct?ous air contaminants as defined by the Bay Arm Air Quality Management BOILER IW,000BTU)
m; P -4 f D
r ❑Ycs ❑No NEW RESIDENTIAL MfiCll. SQ.Ff.
I have read the havarkmS torienals requirements under Chapter 6.95 of the ��
California Health&Safety Code,Sections 25505.25533 and 25534.1 understand that A .8 1993
if the building rices not currently have a ement.that it is my responsibility to notify the
occupant of the requirements which..in ber met prior m issuance of a Certificate of G//r
Occupancy. L l L
Owncr or authorized agent Date 'I ISSUED BY:
OFFICE