27196 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-JKLM;IRILAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27196
BUILDING DIVISION BUILDING PROJECT 10KN'I'TFICATTON
BUILDING ADDRREpEE�S.S: /— 1 ' / /� i - SANITARY NO. AP//PLICVGOONrsuBBstrIIITJAL DATE
I® 14,5-1-s1.V'lC VI�'2r C I1^cd4�j UNIT# LOT#
OWNERS NAME: PHONE: CONTRACT ORIS NAME: I.IC NO:
eo c a,nsell zs-1--788 �Uw�ev N/C CONTROL#
RCI 11'1'ECT/s GIVER: LIC NO: ADDRESS: ❑
'OM'ACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
wy.Z IM1crcby uffimrtha l 3 of the
hasedinss and Professions
Code.and license
with � � �
00 Section 0orb,nf Division 3 ficia,dtand,and Professions Cale.and my license is in PANELS
�dyN❑ I'nllfrand eff«t. UPT02f0AMPS
� Ucenae Class Cmdr
mjy Doc Cunvacmr 201-1000 AMPS SQ.ET.FLOOR AREA S/SQ.IT.
ZO,z ARCHITECTS DECLARATION OVER 1000 AMPS
O Z-- 1 understand my plans shall he,used as Public records.
m SIGNS ELECTRICAL
Q j Licensed Professional
W,W< OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
X06 V 1 hereby affirm that I am exempt from the Contractors License law for the
Wn ' following reason.(Section]0315,Business and Pmfessioms Code:Any city ormenty 'f1MP.METER OR POLE;INST.
[—uJ'O Q which requires a permit in consumer,after,improve,demolish,or repair any structure
C�Q� tv its issuance,alsorc Iheu li...I I...cM1 Oo rile asi d..atemso,
POWIiR DEVICES
Prior 4uims PP Pcmti gnc
m a p O that he is licensed p.rs and m be pnwkim e;of he Con amine,License Law(Ch tueo
a X.X 9(commencing with Section)IKKD of Di vision 3 of the Business and Professions Code) SWI MMING POOL ELECT RIC VALUATION
W_w
in that he is exempt m,refmmand the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES �/�/,1 —
FZa Section 7031.5 by any applicant fora permil,.bjects the epplicarim.civil pcnMrymf WV
ESO rmm
I.asrrcthanun
fvchdrWdollas(5500). NEWRRSIDFJ9TIALELECIR SQ.FT.
nYFo ownerofthepropeny.amyemploy«swithwagesmtheirsole<ompemauon, STORIES TYPE CONSTRUCTION
i3w Il do the work,and rise smiture is not intended or offered for Vale(Sm.]060,Business
Professions Code:The Commnou oe
Ys LocnLaw ds nor apply m an owner of
O pr many who builds or improves thereon,and who does such work himselfor through his
cmplayecs,provlded thmsuch improvements ac an,imended or offeredfim Vde.If, OCC.GROUP RES.UNITS
O
however,the building order of pn¢m is hath a didn one year o improv ei far the owner- TOTAL:
builder will have the burden of Proving that he did num build or improve for purpose of
sale.)' QTY. PLUMBING PERMIT FEE FLOOD ZONE APIJ
❑ I,as ownermf,he propecny,an exclusively conuaaing wins licensed conwe,orsm
a.lruct the pollee,(Sec.)OTa,Business and Professions Code:)The Contractor's
Licenx Lew does nmuPply manownerofpropeny whobuildsorimprovesthereon,and PERMIT ISSUANCE
.be commisfmsich projects with.eomnacunpO Iicensedpeursuam mme Cmmraaors pLTIiR-DRAIN -Wn'I: FA) FGF:SUMMARY
license tow.
❑ l ern exempt under Sec. B&P C for OUTSIBACK FLOW PROTECT.DE E SANITARY Y O FEES N
RECEIPT'#
�y{a Owner WORKMAN COMPEiNSATIONDECLARA''PION DRAINS-FLOOR,ROOF,AREA.C O' SCHOOL TAX Y N
❑ l hereby affirm that l have a cenifeale ofcansem to self-in,um,mface 'recap,of FIXTURES-PF,R TRAP RECHIM9
Wnrkecs'Compereutian lnsumnce or.ecnireed copy lhereaf(Rec'.3800.Lab which PARK FEE Y N
^, covars all employee's code,this permit. GAS-EA.SYSTE -I IN UTI-ETS RECEIPT'#
Policy# BUILDING DIVISION FEES
Company GAS.EA.SYSTEM- 0(EA) PLANCHECK FEE
❑ Cerifial copy is hcmby fumishad.
❑ Certified copy is fila)with the city inspection division. GREASEpND AS .1 ' CNrTOR GRADINGFEE
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASE SOILS FEE
COMI'hNSNI'[ON INSURANCE. 11 1
(This section need not be cantplered lDhe permit is formic hundred dollars($100) SEWER- 'TARY RM EA.20014. fi :RGY FEF,
or less.)
I certify that in the Performance of the work for which this Pamir is iuucd,Ishell WATER HEAT W/V T/IiLI?CTR
nor emQloy any Person in any manner so a to become subject to the Workers PAID
Compcnsatimnlawsof C.Jfomi.. Date WATER SYSTEMG`REATTNG Date Receipt
zZ Apdacanl
O NOTICE TO APPLICANT:IL after making this Cenificare of Exemption,you should NEW RESIDENTIAL PLMR. SQ,PT. TOTAL:
(A hemme subject m the Workeh Compensation provisions of he Labor Cade,you must
� � forthwith comply with such provisions.,,his Permit shall be deemed revoked. BUILDING FEE ��
I!I Q SEISMIC FEE
0..
CONSTRUCTION COONLE.NDING AGENCY
U z Irk in,, affirm that there i,issue (Sce.3 lending97, ivagency for id
nnance of TOTAL: ELECIRICFEE
O he work which this pvmtil'.issued(Seo.309'l,Civ.CJ
Lender's Namc
IendeLs Address QTY. MECHANICAL PERMIT IZE PLUMBING IF.E
L) 1 verify that 1 have rend this,,Plication end sate map the abovetnaioa is MECHANICAL.FEB.
>" W carted.l agree m comply with all city and county ordinances and state relating to PERMIT ISSUANCE
f^ building mmumaruon,and hereby authorize st,exa nufives of this city tr upon me CONSTRUCTION TAX
U Z abuve-mentioned Propcny fur inspection purposes. ALTER OR ADD TO MECII.
(We)agream save,indemnify and keep hamdus the City of Cuno again,,
liabilities,judgmems,cos.and expenses which may is anyv y me ast said City AIR HANDLING UNIT(TO ILM CFM)
in r sa, me he Ota ngofthis pemtit.
G`.— C AIR HANDLING UNIT(OVER IU.W)CFM)
.ignanr d ApplicanVCmnnmmr uce 1!XI TAUS-1'HOOD(WMUMq ]'AID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IOO.a]O RTU) Date RemiptM
Will the aPplicanr or fawns building.'.poop score or handle hazs material
as defined by the Cupertino Municipal Code,Chapter 9.12,and,he Heand Safety HEATING UNIT(OVER 1O0.fW BTU) O
Code.S«tion 25532f.), VENTILATION FAN(SINGLE R[3ID)
❑Yes ❑No
ISSUANCE DATE
Will the applicantor future buildingmccupant useequipment ordevwhich emit BOILER-COMP(3HP OR lOf],0ft)BTU) #� qhazardous air contaminants ah defined by the Bay Area Air Qualianagement BOILER-COMP(OVER/00,000 BTU) P A I D
iatict9
❑Yes ❑No NEW RESIDENTIAL MCCH. SQ.PT.
Ihave read the ha:urdous materials requirements under Chap .95 of the OCT 25 '1994
Cidifomiz Health&Safety Cods.Sections 25505.25533 and 255ss,30. I rstand thato ph pam of he res rot carendy have a t be met n r my mcamem ofmmie.and" theCI TY Or '«capons of rhe requiremen.which must M ma prig,o ixsuan«ofrtificate of V rOccupancy.Owocror umhowed.gem ate TOTAL: ISSUED BY:
OFFICE