27123 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO mJIJAUN(;-ELEturRICA1. PERMIT NO. l
APPLICATION/PERMIT PLUMBING-MECHANICAL. 1
BUILDING DIVISION BUILDING PROJECT IDENRFICA'I'ION
23
BUILD I�NG A�D/DRESS: SANITARY NO. APPLICATIONSUBMITTAL DATE
/ •yI^'//I// ✓� UNITM LOTH /L
OWNERS E: Q� P! NH: e C RACTOR'S NAME: � }IC NO'
a /I I e /�J�[ N/C 'CONTIRGn.0
•ARCHITECT/ENGINEER: LIC NO: ADD RESS: ZA„dy6 G ewe �
CON'IACI': PHONE:
QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
/'� BLDG ELECT PLUMB MECH
.7 _JW
(,/ ERMIT ISSUANCE ��p 21, 0 1:1
LICENSED CONTRACTOR'S DECLARATION pppl,lANCES-RESIDENTIAL 0 RI ION 7
pCZ Iha,by affirm that lab liCONTRACTOR'parecisDECL RATI 9(commencing with
�00F Sedion)la#11 of Division 3of the Business and Professions Code,and my license is in PANELSL/
�dU furl force and effect. ! � ; � _�/�
F Z W Lic,nu Clnss Lica UP TO 200 AMPS _ D/ N{/ s 6^TV J
m 6 L Dam Curb
201-1000 AMPS
F-yZ ARCH]'1'F,CTS DECLARATION S _'.FLOOR ARCA`'1 �$/SQ.FT.
ZOv'— Iunderstandm shall lc used. blit recoils. OVER 1000 AMPS \, )✓�
OZ_p YP pins pts
1—tD SIGNS ELECTRICAL N
Licensed Professional
m,m< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOe. I hereby affirm Nat I am exempt from the Counam rs Licenm Lew for Ne J
W 3 40 ti following reason.(Section 7031.5,Business and Professions Code:Any city in county TEMP.METER OR POLE INST. ( O r
which requires a araiii to construct,alter,improve,demolish,or repair any structure �✓
�' >� prior to its issuance.also fail the applicant for such permit to file a signed statement POWER DEVICES -
Wy C D O that he is licensed pursuant to the provisions of the Contractor's License law,(Clmpt. -
aaoX 9(commencing with Section 9000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC \ Vff
VALUATION
W2m or that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0I1TLE1'S-SWITCHES IXTU
FZQ Section 7031.5 by any applicant for a permit subjects the aPPlicant me<ivil penehy of 1�d Z
nm more than five hundred doll.,($500).
be- F) 1,asowncrofthcpropcny,ormyemployaswiihwagesastheirsoleconpensadon, T'1EWR
RESIDENTIALELECT _SQ.FT. STTYPECONSTRUCI'ION
r,3=° will do the work,and the suuctumisnot intended or offered for sale(Sm.]M4,Business
and Professions Code:The Cmmmiscor's License law does not apply to an owner of ORIpS
property who builds or improves thereon,and who das such work himself or through his
own Idthat such ins t t t ddorofPorcd forsale.If, OCC.GROUP RES.UNITS
employees,thebuilding
or prmcmcn son one
in w c l ^
buwevcgthebuilding terden of pmcntissoldwithinone Ye.ofimprove for
mrhe owncf TOTAL: 3PO0
builder will have the burden of proving that he did not build or improve fur purymu of
alt.).
❑ Las owner ofthapropcny.nmexduxivelycontracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions Code:)The Contractor's
License Lawdasnot apply to an ownerofproperty whubuildsor improvestherwn.and PERMIT ISSUANCE
who contracts for Such projects with aconiractor(s)licensed pursuanuashe Contractor's
License Law. ALTER-DRAINA VIEN'1'-WATER(IEA) FEESUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE 'SIDE FEES
SANITARY YN
Owner Data RECEIPTM
DRAINS-FLOOR,ROOF,AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y
❑ thereby affirm that lhave
tnceorifieniFfi onu,hcm self-insure. Lab C.)which
RECEIPT
FIXTURES-PER TRAP
Wurkers'Cmmpcnsntion lnsnrnnca uraccnified pY th.,of(Sw.38G0,Lab CJwhich - PARK FI3E YN
vrvera sell crop) GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy# BUILDING DIVISION FEES
Comfort � � GAS-EA.SYSTEM-OVER 4(EA) PLANCHECKIEE
❑ Cenifedc pr,is y umish
d]'
Certified copy is filed with Ne city inspection division. GREASFONDUSTRL WASTE INTERCEPT0R GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(His section need not be,completed ifthe posit is forms,hundred d011arapHO0) SEWER-SANITARY-STORM EA.200-f. ENERGY FETE
to less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HEATER W/VENT/IELECfR
not employ any Person in any m as to becom,subject to the Workers PAID
Compensation Lawsof Califumia. Date xn WATER SYSTIBvITR RATING Date Receipt#
0 Z Applicant
2 P NOTICETO APPLICANT:If,after making this Certificate of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
11) becmne subject b the Worker's Cmalmosnon provision of the tabu,Code,you must D®B
a 7 forthwith empty wi nm rmi
with such pvisimts this pet shall b,doed mrevalued. IE
BUILDING ELT
Irl Q a�CONST'RUCT'ION LENDING AGENCY SEISMIC FEF.
w) z Irk for
hickair=t that them is is cued(Sec.
3 lending agency for the performance of TOTAL: ELECTRIC FEE /
U O the work for which this Permit is issued(Sec,3097,Civ.CJ 6 r
W Iede,Name PLUMBING REE
hcaJrrs Address QTY. MECHANICAL PERMIT FEE
V 1 minty that t have read this application and slate that the above information is MECHANICAL IEE
;s' Ltl comet.l agree to comply with all city and county ordinances and state laws mlatingm PERMIT ISSUANCE
F" buildingconswmion,and hereby authorise representatives oflhis city tocater upon the C0NS'1'RUCI'I0N TAX
Uz aline-memiuned property for inspection omposes. ALTER OR ADD TO MECH.
(We)agree to save indemnify and kap hat!.Ne City of Cupertino against
liabilitics,jud eom,rostsund exp l)tuswhi .,w imemeagain.H said City AIR HANDLING UNIT(1A00
'0 IOCFM)
in never, c it ranting ,'i1pc ////// q
AIR HANDLING UNIT(OVER 10,00 CFM)
Signaturcof Apphantq mr�,cm /V ('Date EXHAUST HOOD(W/DUCD PAID
14AZA US MATERIALS DISCLOSURE
HEATING UNIT(T0100,00)BTU) Date Ram",#
Wil l the applicant or rote building occupant store or handle hazardous mumnal HEATING UNIT(0VER 100.000 BT U) TOT(
as defined by the Cape nn Municipal Crbe,Chapbr 9.12,unJ Ne IlealtM1 avJ Salety
Cade,Section 25512( ?
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will theapplicanmrfumrebuilJingrgcupuntuuequiPmenmrJeviee,whiehemit BOILER-COMP(31{p 0R 100,(%10 BTU)
hazardous air commitments m defined by the Bay Area Air Quality Mamagamem BOILER-COMP(OVER 1 W,o00 B'ru)
Uinna?
❑Yes ❑No NEW RIiSIDIEN'1'IA1.MIECII. SQ.II'.
I have mad the h.mdous materials requirements under Chapter 6.95 of the OCT 12 1994
Cnlitbmia I lealth h Safety Code,Sections 25505,25533 and 2553x. 1 understand that
if the building does not currently have a boast.that it is my responsibility to notify the
occupant of the"armament which must be met prior to issuance of a Cenificab of I I f vt v y r LI I I BVQ
Occupancy.
Ownerormalminzedagent Dab TOTAL: ISSUED BY:sllaabi fJ CC
UFM