27144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO H ILDI r-hLEUIRICA L PERM)I'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27144 71 A A
BUILDING,DIVISION BUILDING PROJEC'TIDENTIt'ICA'1'[ON
G l•� L�
BUILDING ADDRESS: SANITARY NO. APPLICA9]ON SUBMITTAL DATE
0060
Tg LOT
OWN'. S ME: PH CONTRA R'5 NAME: LI NO: 7
� G T � 1�1 r! �L I C+ �' 1 [CIS NIC CONTROL N
ARCIII"11?CI'ryNCINEER: rC RE1SD 1 {SIA GI• I D12 I G 5 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
Ql'Y. ELECTRIC PERMIT' PEE
BLDG ELECT' PLUMB MECII
PERMIT ISSUANCE �� El El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAh
Owz I hereby affirm that lam licensedunderprevisime,of C'hapter9(commencing with JO DESCRIPTION
rigWWOO Section]Ip it of Division J of the Business rand Professions Code,and my license is in PANELS
W 11— ran ion 7:W effe
ocI.ij ense Lic.actor S UPT02W AMPS 1
6n• m Contractor 201-10W AMPS 16
I—ON ARCHITECTS DECLARATIONSQ.FT.FLUOR AREA S/SQ,FT.
I understand my plans shall be used as public records. OVER 1000 AMPS
O ^� l
O
rc,'^ W SIGNS ELECTRICAL Ir
Q�d Fp+�.'.al Licensed Professional ^
cuOW OWNER-BUILDER DECLARATION SPECIAL CIRCUI'UMISC. _
XOyU I hemby alJimr that I am exempt from the Coammurs License Law in,he / � % I—'l 'l i('
W3av~i following remount.(Station 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE.INST. \ 1 J �f
F LL O< which requites a permit to construct.altar,improve,demolish,or repair any stmemre " A
z1i2to its issuance,also the licant for such Permit file a signed statement POWER DEVICES } \A' 1
pdur rtquims pp pcnni 8 t ` 1
W C 0O that he is licensed pursuant to the provisions of the Contncmr s Licenm Law(Chapter SWIMMING POOL ELECTRIC /"1 _
.Xa 66 9(commencing with Section 7")of Division 3 of the Business and Professions Code) __ ALUATION ---•r'
,_y or he is exempt hcmfrom arta Ne basis for the alleged exemption.Any violation ofUTLETS-SWITCHES-FIXTURES
Smdon 7031.5 by any applicant for a permit subjects the upplicanno a civil penalty of
nor marc than Eve hundred dollars(SSW).
�FrO NF.W RESIDENTIAL L1ECfR SQ.FT. STORIES TYPE CONSTRUCTION
22 ❑ Lmowrk,and the somnY.orm of intnded(it offered
forsalei(sole compensation,
y3. willdothe work.and the he ComisnorimtcnJnoc Lawdoe.0 not e(See
1.an Business
and Pmfessions Cale: pr Contractor's and
Law due,not apply to an owner of
own cio who
ev.promriopmvesthereon,andwhoime notsuch work himselfofthrough his
amploYccs.proviJed that such improvemmnlsxrcnot immadcdorofferedformlc.IL OCC.GROUP RES UNITS
however,the buildingor improvement is sold within one year of emopletion,the owner
builder will have the burden of proving that he did not build or improve for purpura of
QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ 1.its the project
(Srvpeny,ane in ss and Professions
C li,)t Th Contractors icmw the pmjat(Sec.]014.Business and Professions Code:)The Contnnand
Licenw Lawdocs not applym an ownerofmopenY whobuildsorimproves thereon.and PERMIT ISSUANCE
who contracts for such pmjens with acomtmemr(s)licensed pursusere the Co domim's
License Law. ALTER-DRAIN&VENT.WATER(EA) FEE SUMMARY
❑ I am excmpr under Sec. ,B&P C for this renwn BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dare RECEIPT 4
DRAINS-FLOOR.ROOF,AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ .mthatlhnvc acenilicure orennunt m,elf-insure,or asxnificum of FIXTURES-PERTRAP RIiCIi1P1'A
Work...0 mt,peasmion Insurance otucmifeJ empythereof(Sec.3gW.l.ab CJ which PARK THE YN
povers all employer's under his permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RLCLII'1 a
cy a BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVFR 4(Ii A) PLANCHECK EEE
❑ Certified copy is hereby fumished.
❑ Certified copy is filed with the city inspection division. GREsSFI1NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF L, E,MPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one,hundreddullan(SFW) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
ca less.)
Iccnify that in the perto rmitim.f1he work far which this pe am,is issued,lshall WATER HEATER WVF,NTpELF,Cflt
not employ any person in any m as br become subject to the Workers' PAID
Compensation Lawsuf Califomia.manner
so WA TER SYSTEM/TREATING Data Receipt#
O z Applicant
O NO'I'ICH TO APPLICANT:ILaBe(making this Ccnilicam of Exemptionyau should NEW RESIDENTIAL PI.MB. SQ.FT. 'T'O'TAL:
UO become.whjecnuthe Worker's Compensation provisionsofthc Labor Code.you must
a � forthwith comfit,with such or this permi lsham
ll be deemed revoked. BUILDING THE
provisions
LEI
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm than the.is a cnnswctian lending agency,for the performance of
U O :
the work for which this penrdr is issued(Sm.3M7.Civ.C.) TOTALELECTRIC FE
Lenders Name
U" F- 1<nderx Address QTY. MECHANICAL PERMIT FEE PLUMBIN;4fFE
V 1 certify that I have mad this application and.state that be above information is Mf: C FEE
>" correct. I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F' UO building construction,andM1 eby authonm representatives ofthiscity to enter upon the CO l ION TA
(� aMwcmeminneA propeny fo inspection purposes. ALTER OR ADD TO MECII.
(V u tee to save.in mnify and p similes,the City of Cupertino againsl
Iiabillzel Jgmenls.cosls dexpenw hich mny in any way accrue against said City AIR HANDLING UNIT(TO 10.001 CFM) �
in ttmtty ncc of c gran ng of Thi
16 1 E/,� AIR HANDLING UNIT(OVER 10.000 CFM)
Srgnreat Ap Cantmcmr Date EXHAUST HOOD(WIDUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW.000 BTU) ifilik Reseen a
Will the applicant or future building Mcuptint stare or handle haardous material HEATING UNIT(OVER 100.004)BTU)
as deGnN by the Cupertino Municipal Cole.Chapter 9.12,and the Health and Safety
Cad,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISS NCE DATE
Will theupplicanmrfutum building occupant use equipmentordeviceswhichemit BOILER-COMP(3HP OR Itp.0F0 RTU) R(�es
hnmNons air contaminants as defmN by the Bey Area Air Quality Management
BOILER-COMP(OVIiN FIq,00 BTU) P {`!
01 —
1 Dwrict?
❑Yes ❑No NEW RESIDIiNI'lAl.MliCll. SQ.F1'.
I have read the h esurdoas material,me,mmems notice Chapter 6.95 of the OCT 11 1994
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand That
V the building Joos and curtnnly M1ave o tenant,0 nt it is my responsibility to notify the I
I^ ry
occupant of the myats be met which must ran prior to issuance of a Certificate of .V 1 1 Ur liUrCh I
Occupancy.
Owner m(amhmmed#gem Date TOTAL: ISSUED BY:
OFFICE