27032°-APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
9
CITY OF CUPERTINOBt,".1 'i -.11TTRICAL
APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING DIVISION BUILDING PROJECT' IDKN'I'IFICATION
PERMIT NO.
27032
B171�NG ADDRESS: � 1��� /5
3 (I7\ Arm UNIT# LOT*
SANITARY NO.
APPLICATION
�SU/N`MH
SUBMITTAL DATE'
l JJ
) ERS NAM IONP _ /
UM J'1
C R'SNAM ):
N/C
CONTROL#
HCHITECr/ENGI .ER: LIC NO:
`J
mN cf: solemn:E
QTY. ELECTRIC PERMIT FEE
BUILDING PIiRMl9' INFO
HIAG ELECTPLUMB MECII
�
PERMIT ISSUANCE
1:1 El
]Kz
LI E,NSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed underprovisions of Chapter9 (commencing with
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
000
tW
U
C'y �
Senior ]000).( Sof the Buainna:mJ o Cale. and mY license is in
license Class vlslon Lie# on
fiecor" and ct
PANELS
UP TO 201t AMPS
201-l(M AMT'S
9=o,
=_
0
n F W
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CLQ
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Dam Cnmmctor
ARCHITECT -S UEC 1<
I understand my plans shall be used az public records.
SQ. PI'. 4100R AREA
8/SQ FI'.
OVER I"AMPS
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
1 herchy affirm that 1 um e#cmpt Item the Contractors Liccnsc law Emilie
tollowing taxon. (Sce ion 7031.5, Bnsincar lmd Professions Code: Any city ., county t
which requires a perminoconstruct, alter, improve. demolish. or repair any 9ruct.,
its issuance. also lards the applicant for such 't to file a signed sentiment
prior ray PP peso:: gn
that he is nci ngM promardSectio to the provisions of the theContractorssinLicense Law (Chapter
9(conuncncingwith Scnion]iNplof Division 3ofnc� Business and Prvfessions Code)
or that he is e#empuherefrom and the basis for thealleged eAny violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
.t more than f ve hundred dollars($500).
n❑ I, asownernf the property.ormy employees with wagesastheirsolecompensation,
will Ju the work, anJ tM1e mm�ure is nm imcnJCJ ser offcredfor svle(Sec.]044.Business
SPECIAL CIRCUITIMISC.
TEMP. MITER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
Lxemption. /�.
7 %��/�/ /1/1
/si f
OUTLETS - SWITCHES - FIXTURES
NEW RESIDIiNT1AL ELECTR _SQ. Ff.
STORIES
TYPE CONS'IRUCI'ION
and Professions Code: The Contractor's License Law does no, apply to an owner of
propeny w hn bu it ds m i .proves thenomr and who does sac h work him ad f or through his
cmpl.yus, prnviJedthm such improvcmcntsaren.rim<ndedur.ffemdfor sale. IL
OCC GROUP
RES. UNITS
TOTAL:
however, the building or improvement is sold within one yearofcompletion, theowner-
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT FEE
FLOODZONE
APN
sale.).
❑ I,asownernllbcpmperty,mmexulualvelymnirectingwithlicenscdc.soman.. in
consumer the project (Sec. 704q Bminess and Professions RNie:) The Contractor's
LicenseLawdresem apply madownerofpropeny who mildsofimprovestharon,end
PERMIT ISSUANCE
whoemounces far such pmjecuwith a conoadoes) licensed pursmnnaabec.nmcmr's
License Law.
ALTER - DRAIN&VENT- WATIik (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
❑ I am exempt under Sa. , B & P C for this reason
SANITARY YN
Owner Date
DRAINS- FLOOR, ROOF, AREA, COND.
RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ Thereby efErat lhatlM1aveaccnifcme of<onsemmself-insurq oraartificme of
takers'Compcnsudo�9,ln�su c .certi%fied�c�n`B'Y�*h#(/of(Sec. 3800.Leb Cd which
rovers all employclNfitFkrd seO
Policy II�S'r-�f 77 ��WWII
SCHOOL TAX YN
RIiCGII"1'#
FIXTURES - PER TRAP
PARK FEE Y N
RRCISION
GAS-EA.SYSTEM-1 INC.40UfLFTS
BUILDING DIVISION FEES
Cm any
GAS - EA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
Cmified aspy is M1erc seJ.
GREASEANDUSTRL WASTE INTERCFPfOR
GRADING FEE
❑ Cenilied copy is fled with the city inspection auto .
CFR'1'IIICATE OF EXEMPTION WORKERS'
GREASBTRAP
SOIhS PIiG
COMPLNSA UR'NCE
SEWER - SANITARY - STORM EA. 20IFp.
ENERGY FEE
(This section need nm ecdifthe pe- is for one hundiond dollars (SHO)
or less.)
I WATER HEATER W/VENT/ELEM
PAID
Date Raceipt#
lecolyrhatinit,tperformance offhe work for which this permit itinsued. lahall
nm employ any pert, n in any manner so as m become subjem m the Workers'
ComPpdlpensmion Lawer C.Homoia. Dnm
a
NOTIGE'fQ API'LI ANT: IL nod, nmkiIrg f ate of Exe iia hoaIdj
WATER SYSTEM/REATING
NEW RESIDENTIAL PLMIL SQ. FT.
TOTAL:
.N.
1 [�
becomesubjecnnth Worker's Compensation oftheh you must/
forthwith comply wi isue pm,' : this is dee o
CT NL P/ (
BUILDING FEE
SEISMIC FEE
7r
) O
d11\fll
I hereby affil than como o I ding a en to a peffamance
the work for which bis per vsued (S � ], Civ. Cd
IsndcA Name n
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Addmsa
z
z
1 certify the I have read this epplicmion tate tM1ai the above information is
nut. IagreeIt earn ply with all city andr yoNinances moisture laws relating..
build; onamcion,andherebyamhod epresentutives nidus city menrerupon the
props pec
none onmionr ny for ins
PERMIT ISSUANCE
MECHANICALFEE
ALTER OR ADD TO MECII.
CONSTRUCTION TAX
AIR HANDLING UNIT (TO IH,UN) CPM)
keepmes.
(W) a Inde y sandes keep hmmless the Ci of Cu nine st
Iia lit; ss costs expenses which may in an ay ecrue wins rd City
AIR HANDLING UNIT (OVER 10,000 CFM)
mttll.
'
EXHAUSTHOOD(W/DUCq
PAID
Sig:mmreof Applican./C.n.rector Date
HEATING UNIT (TO 100.000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
,aid Receipt#
HEATING UNIT (OVER 100,000 B' I' U)
TOTAL:
Will the applicant or future building occupant store or handle hazardous material
m defined by the Cupcnino MwiaiPal Cidc. Chapmr 9.12, trod ibe Ilwhh antl Salety
VENTILATION PAN (SINGLE RESIDE
Code, Section 2.5532(a)1
❑ Yes ❑ No
icanmrfumre herrat
BOILER - COMP (3HP OR Im'" BTU)
ISSUANCE DATE
Area it Quality
air c.ntvmin.nfa ss defined by the Bey Area Air Qualify Mawgcmen.
ousWill air co RdfimJ by the
BOILER - COMP OVER 100.000 ITU)
Distdn�'
SEP 251995
NEW RESIDENTIAL MECII. SQ. Ff.
❑ Yes ❑ No
1 halo revel the hazardous mmcriels requirements unJcr Chapmr 6.95 of the
GI I i VF 1#Ur" ti�t�Illjh/l�/%
California Health & Safely Code, Sections 25505, 25533 and 25534. 1 understand that
if the building Jas not currently have o mnani. that it is my responsibility m notify the
cupied of he requimmenis which must be me, prior 10 issuance of a Cenlficare of
Occupancy.
V
ISSUED BY71211F?T�
Owner.. vmh.rivcd ageed Date
TOTAL:
OFFICE