27748 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLECRI A- PF.RMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL J n O
BUILDING DIVISION BUILDINGPROJECT IDENTIF'ICA48
'TION /
BUILDING ADDRESS: ��j7�]r��J�}/�!`•-�a` SANITARY NO. APPLICATION SUBMITTAL DATE.
2 1 V/w� L i '� UNIT# LOT#
OW IiRS MG r H ACION'SN
I LI/ _�I fG._ N/C CONfHO1,N
•A IC
RCHI'11iCf/ENGINEER: LICNO: AD RISS:
2- aA a
CON'I'ACI': PHONE: RIIILDING PERMIT INFO
Q9'Y. ELECTRIC PERMIT FEF,
BLDG ELECT PLUMB MET
PERMIT ISSUANCE ❑ El "SC
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL
9
OCZ I hereby affirm that l am licensed under provisions ofaripler (commencing with JOB DESCRIPTION
Y1001� Sc,huaLYX
? p of Division 3 of the Business and Pmf Wmas Code,unit my license is in PANELS
F�Uky f It In deffec. `
E- iccn C Contr UP T02 AMPS n ^
m a DaeComractor 2UI-1000 AMPS I
SQ.i°Il jLO AR J b S/SQ.FT.
OFO_0ARCHITECPS DECorON
OVER I00l1AMPs
understood my plans fiall be used as publlicicrecords. Is ords. f p
F:,y F4] SIGNS ELECTRICAL
Q Y W j Licensed Professional •�t \\ B r`/�
Orc6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/AIISC. - \y —T IrA`
dU I hereby affirm mut I am exempt from me Contractor's License Law far the w J
W3LLy following reusoa(Secliun?0315,Business and Professions Code:Any city or county TEMP.METER OR POLE INST,
O J which inquires a permit to construct,.11c,,improve,demolish,or repair any sienna.
i� prior to its issuance.also requires the applicant forsuch permit o file A signPOWER DEVICES
statement
W C Q 0 that he is licensed purxu um to the provisions of the Contractor's License Law(Chapter 1
aWo� Y(commcncingwith Seri un?000)o[Diviron 30[the Business and Pro[essl.ns CaSWIMMING POOL.ELECTRIC
VALUATION
W_y rthm be is exempt therefrom and the bass for the.1 kind exemption.Any violation of OUTLETS-SWITCHES-FI%'TORES
FZ. Section 7031S by any applicator for a permit subjects the applicant to a civil penahy of
C�pnorethufive ve hundred do[[.050B) NEWRESIDENTIALELECIR SQ.FT.
❑ot mLaaownerofthc prnpeny..rmyemployees withwageaasthcirsolecompcmatioq STORIES TYPE CONSTRUCTION
i3=e willdo the work and the structure isanintended ornlfemd forsale(See.INVIl Business
and Professions Cale:The Comraumr'a License Law does not apply to an owner of
property who builds or improves thereon,and who docs such work himself or through his
wn employees provided that such Emproven¢msartnot earrdcplmoffeml fors ale. r.
OCC.GROUP RES.UNITS
however,(hebuilding simprovemcm issoldwithin one yearofmmove fordmowna-
boildcrwillhavethebuNcn.f that he did not build or improve for wof TOTAL:
proving prove Purpo.
sale.).
❑ hmownerofthe Pmpeny,am exdunivelycomramingwith licemed conhamursm QTY. PLUMBING PERMIT PEE FLOOD ZONE APN
consumer the project(Sec.?004.Business and Professions Cade:)The Canwcmr's
License law darn.,applyman ownernfpropcny whobuildsorimproves thereon,and PERMIT ISSUANCE aa,
who contracts forsuch pmjects with a conhactor(s)licensed pursuanuothe Contractor's of TER-DRAIN iF
&VENT-WATIiR IFA)
License Law. FEE SUMMARY
❑ 1 um exempt under Ses. ,B&PC for this rearm O IS DE THIS
BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner ENDate RECEIPT p
• DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMPSATION DECLARATION TAX Y N
CII hereby ufthm that l have a cenifcate ofcommrno self-insam.nracerificareof FIXTURES-I'IiR TRAP RF;CEIPfa
Workerv'Competmsadorlnsuranceoracenifiedcop thereof(Sea.3800,Lub CJwhich PARK FEE Y N
polrs all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT N
icy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHF.CK FEE
❑ Certified copy is herby furnished.
❑ Certified copy is Cited with the city inspection division. GREASEIINDUSI'RL WASTE INTERCEPTOR GRADING PER.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thin section need not be completed fire permit is forms hundred dollars(91001 SEWER-SANITARY-STORM LA.2001T. ENERGY IPE
or less.)
I certify that in the Performance of the work for hich this permit is insned,i shall WATER HEAT ER W/VENIOELECTR
ploy an,sera n y nnner t me sablect w,Ne Workers' PAID
�mmpcnsa,pglsgry Cali Ouse WATER SYSTEM/ptEATING Date Receipt
O A'pplicum—cV AA
NOTICE TOAPPLICANT:if,ofmanaki.,oris Cenifeme of Exemption.ynushould NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
0 become subject o the Worker's Compensation provisions of the Labor Code,you must
� ? fonhwith comply with such provisions orchis permit ahaH be deemed revoked. BUILDING FEE
LT7SEISMIC FEE
Q
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a conmructi.a lending agency for the performance of
U 0 the work for which thin permit is macd(Sec.319),Civ.CJ ELECTRIC PER
Leader's Name
D"' TY. MECHANICAL PERMIT FEF, PLUMBING IEE
U Lender's c Address Q
V 1.I tut that I comply
mat this application And stem that an above information g is MECHANICAL FEE
correct.Ingrce nm comply with all city and county nrJinmees and arm laws relating to PERMIT ISSUANCE
(•"' kO kO builiingamstruction,and hereby ashori'ze representatives ofthis city menter upon the
V Z above-mm�tioned n for inspection ALTER OR ADD TO MECII. CONSTRUCTION TAX
props Y if purposes.
(We)agree nt save,indemnify and keep harmless the Cityofs agar n.against
Iiabilitiea,juJgmen¢,co aM enpcnas which may in any way accrue egei st. id City AIR HANDLING UNIT Tf0 l0,g10 CFM)
o he gr ntin this permit.
4 AIR HANDLING UNIT(OVER 10,000 CFM)
Signature.!ApphcaaVCummcmr am EXHAUST HOOD(WMUCI) PAID
IIA7ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Wi 11 the spot cam or future buil ding mecupanl store or handle hacardots material
as def ed by the Ca,mimm Municipal Code,Chapter 9.12,ani the HealthDEALING UNIT(OVEN 100,IXq BTU)and Safety TO AL:
Calc,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
BOILER-COMP QHP OR IM."BTU) I§SUAjJCF;DATE
Will the applicant or future huilJingoccupam usecyuipmem-devices which emit
• haaanlow air contaminants s defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 1011,000 BTU) V
District'( `A
❑Ycs ❑No NEW RESIDENTIAL MF.CH. SQ.FT. Y 9 n
1 have reed the hm.urdous ammrlals regatrtmen,s under Chapter 6.95 of the /� k�
California health&Safety Code.Sections 25505.25513 ant 25534. 1uaderstan Imhar /TY Uh Luta
ifthe builthng dces not currently have a teras.that it is my responsibility m ummify me Q��U
cupant of the requimmems which must h met prior to issuance of a Certificate of
Occupancy.
Owner or authorized agent Date 'IUTAL: ISSUED BY:
OFFICE