27160 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOBf,,kokNN2'.-ELFds`TRL AI. PERMIT NO.
APPLICATION/PERMIT PLUMBING.-MECHANICAL A�aI C 0
BUILDING DIVISION BUILDER; L 1UNG PROJECT IDENTIFICATION
BUILDING ADDRESS:fT,��,��II SANITARY NO. APPLICATION SUBMI"11At,DATE
UNIT# LOT# L6 �Z
OWNER �f� AME: PHONE: CO ACI' R' NAME: n I.ICNO: / kJ
T � y�j NIC CONTROL#
pROU ECf/ENGINEER: LICNO: ADD -S El
CONTACT:
E
�ro
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
— "M EL PLUMP MEC{
PERMIT ISSUANCE " kLP(
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES-RESIDENTIAL
Oy.Z I hereby affirm that l am licensed underprovisionsof Chapter9(commencingwith LOB DIiSCRII'I'ION�/��
u100F. Section]I%ID)ofCDiiivvision Softhe Bminessmd professions Cade. it my license is In PANELS 1' �\(1 QaJ w1R Xy.g�
F�6ZyVj LicelnuCass�fr)m f, Li UP T0200AMP5 V^V•tt Y'����lV V�
vs,2�vai D Ut TS mr 201-1000 AMPS SQ.PT.FLOOR AREA EISQ.FT.
% NCHI'fIiCTS DI?CLARA'TION OV17R 1000 AMPS
0z`?G I understand my plans sial be used as public records.
F m F W SIGNS ELECTRICAL
Qy�J Lirm,d Prnfexsionnl
�qyceQ OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. r
X OaU I hereby affirm mat I am exempt from the Cnntmcmes License Low for the
m3LLy followingreamn.(Section'7031.9,Business and Professions Cade:Anycityorcouity T'EMI'.METER OR POLE INST.
F•LL OQ which reyulres a permit to construct.alter,improve,demolish.or rcpar any auucture
f�}5 priortoitn issuance,atm reyniresthe applicant(nrsuch petmitio file aligned statement POWER DEVICES
takj L'Op that he is licensed pursuion1.he powisiom of the Contractor's License Law(Chircer SWIMMING POOL ELECTRIC
aX 9(commencing with Section 7000)of Division 3 of he Business and Professions Code) VALUATION
m_w or that be is exempt therefrom and the basis for the alleged exemption.Any violation or -'
> Section 0031.56 applicant aperion vabjecls the mplicantto a civil sh f OUTLETS-SWI'I'CHIS-PIXTUHI3
FZ_,a Yhundre man pen Yo ` ldJ
K�orn more man five hundred dollars(b5W). NEW RESIDIi IALELECTR S FT.
n❑ I,usuwnerofinepmpeny.ormycmpinyeeswitn wages ustheirsolccompensatinn, Q' STORIESY TYPE CONSTRUCTION
y3°—° will do the work,and the structure isnot intendedoro(fend forsae(Sce.7016.Business
and Professions Gale:The Contractor's License Law does not apply to an owner of
property whobuildsorimprovesthemon,and whodoes such work himself orthrough his
employces,providrdthatsuchimpmvemmntsarenotintendedorofferedforsae.If, OCC GROUP R&S.UNITS
however,the building or improvement is sold within one yearofcompletion,meowner-
builder ,will have the burden of proving that he did not build or improve for propose of
sale')' QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ 1,as owmer ofthe property.am exclusively contracting with licensed emmaemrsm
consumer the project(Sec.7014,Business and Professions Code:)The Contractor's
License Lawdcesnotap,lytoanoweer.fpropcnywhobuildsorimpmvcsthcrcon,and PERMIT ISSUANCE
who contracts for such projects with it contructor(s)licensed pursuant mthe Contractor's
License Law. ALTER-DRAIN&VENT-WA TER(G) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason OUTSIDE FES
BACK FLOW PROTECT.DEVICE:
SANITARY YN
Owner Dare DRAINS-FLOOR.ROOF, COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCfI00LTA% YN
❑ I hereby affirm that l have a certificate ofeensent to self-insure.or a ttnificae of Fl%TURES-PGRP RECHIP0
Workers Cumpensatianlmunnce orncenified copy thercogSec.3800.Lab C.)which PARK PER Y N
covers all employees under his permit. S- ..YSTEM-I IN ITS RECEIPT#
Policy# BUILDING DIVISION PEES
Company AS- A.SYSTEM-O . 4(EA) PLANCIIECK FEE
❑ CeniGedcopyishereby famished.
❑ Certified copy is filed with he city inxpection division. GRFASPJI USTIIL WAST NTER OR GRADING FEE
CHR'HFICATE OF 17XEMHION FROM WORKERS' GRIiASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need mol Mcompleted ifthe permit is far one bun dollars(E100) SEWER-SANITARY-gTOR .200FT. ENERGY FEE
or less)
I ttnify thatimhe performance of the work(or which this pc it isiasued,lshell WATER IIEAT' WNENI/ELECB
not employ any Person in any manner so res to become subja to he Workers PND
Compcmasosn Lais—f Callfomia. Date_ WATE . EATING Dam Receipt#
0 z Applicant
Z 0 NOTICE 10 APPLICANT:IL after making this Cenificata of Exempt\yhrId NE ES AL PLMB. FT. TOTAL:
f•" In Y<utme subject m the Worker's Compcnsmlon prov s ons of the Lmbor .t� forthwith comply with such provisions or this PermitShall be clamed BUILDING FEECONSTRUCTION LENDING AGENCY SEISMIC FEEzI hereby affirm thatthercis a construction lending agency for the of ELECTRIC FEE
V Q the work for which this permit is iaxned(See 3097.Civ.C.)
t<ndcA Name PLUNKING Fl3C
D' F L<nJcr's AAdmss QTY. MECHANICAL ,KNIT FEE
L) 1 certify that 1 have read this application moisture that the above information is MECHANICAL ITE
>• W ck,..Iagm mmmplYsvithalleityeMenunryordinances and smm laws relatingm PERMIT ISSUANCE
f•-' building.....carrier.and herebymwbortre meresenmtivesofthiscitY to emerupordic CONSTRUCTION TAX
(� '� ano,okentioned pm,eny for inspection purposes. ALTERORADD MECII.
(We)agree to save.indemnify and keep harmless the City of Cupertino against
Ilubllities,'udgmems,ants and expenses which may in any way ace eagain, dCity IR HAND GUNIT(TO 10,000 CPM)
n cook
ucnce nl the granting mkape il.
AIR HANDLING UNIT(OVER IU.f%10 CPM) �•
ignamre of ApplicanU ommemr I true GKIIAUSTHOODGVMUCU /-
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Recript#
Will the applicant or future building occupant wee or handle hvardous material HEATING UNIT(OVER 100.000 BTU) TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Heath and Safety
Cede.Section 25532(a)'1 VENTILATION 17AN(SINGLE RESID)
❑Yes ❑No ISSUANCE DATE
Will thea applicator or furore buildin tuseeui enmrdeviceswhich emit BOILER-COMP(3HPOR 100,IXNI BLU) -.
PP goccuPan q pm 1
bra ems air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District'! ❑ '/
9BYen ❑'Nu NEN
WRESGMI'IALMEC{I. gQ.PR � � 319
el
1 have mad the faayC us mmeriaL reyuir25533 under Chapter 6.95 of the -l i VP
Cate building
do&of cry Cede,Sections 25505,25533 and 8536. 1 ily to ntanf mhe L P
L
if building does not currently have a sham,that it is my rcspnce of
a notify hr CfI .0
� ecupnm or the requirements which must he met prior m issuance of a Cmificme of
Occupancy.
Owner or arilk ed ages Dam ' ISSUED BY:
OFFICE