27229 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Rvrt.BING-MECHANI A. PERMIT NO. 7
BUILDING DiVIs1oN APPLICA•1'tON/PERMIT INGPRJECI IDIIANII;AL
BUILDING PRIIJRCI'IDENJ'IFICATION
229
BUILDING ADDRESS ('� SANITARY NO. APPLICATIONsuRsorITAL DA'IT
�/ UNIT# LOT#
OW M1; 'NACON'rRACI'OR'S NAME: LIC NU:
VS L/ N/C
•A TEC `INR LIC NO' ADDRESS:
CO TACT: y S� PHONE: a ��2f Sf '� "' - . :BUILDING PERMIT INFO
QTY ELEUMIC PERMIT: FEE
_O s1 :w°a '2E1[F5gxbif 4"'TM1 'n BLDG ELECT PLUMi MECII
/a PERMIT ISSUANCE T�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES.RESIDENTIAL �+� JOB DESCRIPTION
QMz Ihinffum Nm Into licensed andm,,.vlsionsofChapter9(rommeneingwith
u100 Section RlIX)of Division 3.fthe Business said Pr.fessions Code,and my license is in PANELS
FFX W I full force and cffttt.
<F L License Class Lw.# UP TO 200 AMPS
H?y Uwe Contorted',Dr 201-I000 AMPS SQ.IT.FLOOR AREA 1;/SQ.IT.
ZOsn? ARCHITECTS DECLARATION OVER 1000 AMPS -
O Z—0 I understand my Plans shell be used es public mecods.
F f-; SIGNS ELECTRICAL
6 I.iccnscd Poofessionul
m< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aOyU I hereby affirm That 1 am exempt,from the Contrnanr's License Law for the
'Y+wy following om,rn.(Section 9131.5,Business and Ponfiwions Owl,Any eft ty.fcoumy TEMP.METERORPOLEINST. �\
F W 0< which requires a permit to conswet altar,improve,demolish,or mPair any aweture
Y� prior to itsissuance.also recures the applicant for such permit to file a signed smtemem POWER DEVICES
c <0 that he is licensed Punuanmodo,provisions of the Contractors License Law(Chapter
aaxQ 9(Commencing with Section 9000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
�
W_rn or that he is exempt dicrefmm and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
FZY
Section 7031.5 by my applicant for a permit subjects the applicant to a civil partially of
< nam mom than five hundred dol Ins($500). NEW RESIDENTIAL F.LECTR S FT. F
ce -❑ I,asowneroftoe properly,manyemployces with wage4atheirsolecompcvation. Q' STORIES TYPE CONSTRUCTION
at will do the work.and the structure is not intendW or offered for aide(Sec.J014,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himselfur through his
OCC.GROUP RES.UNITS
ownhowever,the ba,pmvidd that such impmvcmwithin notimrofOsmpRfirtd fm.m If,
howcvegthebuilding urimprovementiscoldwithinoneyear of completion,theowner-
huilduwill huvc Ibe burden of proving mhum hedid not build or improve for pupgmse of
sale.). - PLUMBING PERMIT FEE FLOOD ZONE APN
[I1, sownerofthcpmpenyumexclusivelyconinctingwithlimnsdcontractomto QTY.
Lnruct the project(Sec.014,Business and Proassinns Codc:)The Contmaors
icense,law does not apply teunownerol Property who build,or improves thereon,and PERMIT ISSUANCE
whocu forsuch pmjens won acomrunorts)licenced pursuanitmthe Contractors
License.Lnvlaw. ALTER-DRAIN&VENT-WATER(FA/ FEE SUMMARY
❑ 1 an,exempt under Sec. .B&P C lis this reasonBACK FLOW PRO'1'ECT.DEVICE? OUTSIDE:FEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREACOND. •RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLI, 'AX Y N
❑ I hereby affirm lout l have acertificam ofconsent toself-insuce,ora cenifiwta of FIXTURES-PER TRAP RF. #
W.rken'Compensation Insumnemr a eenifid copy thereof(Sec.3800,Isb CJ which PARK FEE
cawc,rx all employee,mala this permiv GAS-EA.SYSTEM-1 INC.4 OUTLETS 11 RLCEI
IX
Policy It BUIpjDIGCjVIANFEES
Company GAS-EA.SYSTEM-OVER,l(FA) PIANCHECK
❑ Cmified copy is hereby fumishd.
❑ Cenificd copy is Hld with the city inspection division. GREASE/INDUSTRI.WASTE IM'ERCEPfOR GRAI iF• E LIM
�f
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP SOI S �•
COMPENSATION INSURANCE
This section need not be completed ifthe,c,mit is for one hundred J.Ilaa l$11X)) SEWIiR.SANITARY-S'IORM IiA.200FT. I?NERGY THE
or IcV.)
I ecnify that in Ne performance ofthe work for which this permit is issued,I shall WATER HEATER W/VE- /ELECTR
not employ any person in any manner so as to become subjut to the WorkersPAID
z Ccmpvrwdi.n Lawsof Celifomic Date WATER SYSTIivbTRGTING Date Receipt#
pp
Alicant
z 2 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PI-MB. SQ.FT. TOTAL:
F' Ln become mhjecuo the Work&,Compensation provisions tithe Labor Gyle,you..in
> forthwith comply with such provisions or this permit shall be deemed rtsokd. BUILDING FEE /#
Q CONSTRUCTION LENDING AGENCY SEISMIC Il3E at`�
I hereby affirm that there is a construction lending agency for the performance of
V 0 the work for which this permit is issued(Sec.3097,Civ.C.) A ELECTRIC
lxnder's Name PLUMB O .E
Landds Address QTY. MECHANICAL PERMIT PEE
0 U 1 certify that 1 have read this application surd nate that the above information is IPAID
AL FRIT
correct.I agree mcomply with all city and comity.dinanees and state laws relam,ur PERMIT ISSUANCE
1" p"
building nm.nmdinn arta 'vera reaenmtiva of thisciry memerupon the
bMwe-memioa HONT X
V z u ALTER OR AILD TO MECH.
(We) cp less y of Cupertino eBam.
I mhili! uswhm nonyway ac cegainst said City AIR HANDLING UNIT(TO 10.000 CPM)
We a n uh s n
AIR HANDLING UNIT(OVER 10,IX10 CFM)
Signatumof Applo Date EXHAUST HOOD(W/DUCT)
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date N, Receipt#
Will the applicant or future building occupant store or handle hverdous material HEATING UNIT(OVER 100,000 BT U) TOTAL:
as dcfi.ed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? VENT'ILATTON FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE-DAI F:
Will thea plicamorfutum building tweeui mentordeviceswhich emit BOILER-COMPQHPOR I00,(010B'DE
P Bmacupan q p
hn andro x air comammants s defined by the Bay Ara Air Quality Mam,mens BOILER-COMP(OVER 100,006 BTU) P A
�Dlauier? 1 p.
❑Yes ❑No NEW RESIDER'I'IAL MECII, SQ.Ff.
l
1 have read the haradmi s materials mgairemems under Chapter 6.95 of the APR 18
Culifomiu I Iwhh&Safely Gde,Sections 25505,25533 and 25534.I understand that
If the building docs not currently have a tenant,that it is my responsibility 10 runty the UF
#/
cupmt of the na,mocmarns which most be met prior m issuance of u Certificate of f I
Occupancy.
Owner err amhoriu0 agent — Dane ( �: IgSUED BY' �f�
OFFIC