27121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINORUILIHNc-ISLECTRrCAI. 1-17RMITNO1 '1
APPLICATION/PERMIT PLUMBING-,MECHANICAL 1.
BUILDING DIVISION BUILDIN G PROJECTIDEN'TIFICA'TION
BUILDING ADDRESS:s� y, SANITARYNO. APPLICA ONSU MITFALDATE
UNIT# LOT#
OWNERS NAME: PHON^ CONTRACT'OR'S LIC NO: N/C O Lp
ARCH]FECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PER INFO
J1/I QTY. ELECTRIC PERMIT FEE
�]I -�/04- PERMIT ISSUANCE. '� BLD PLUMB iCll
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Myst Ihereby affirm that l am licensed order pt..Wartm Chapter 9(commencing wish JOB DESCRIPTION
FOO Seemas/0)0)of Division 3 of the Business and Professions Cod,and my liceme is in PANELS
CUA Licll nseCand cffed. UP TO 200 AMPS y'�
FZ� License Class Lia. V
w<p' Dare Contractor 201-1000 AMPS
SQ.FT.FLOO AREA $/SQ.IT.
,)FONZ ARCHITECTS DECLARATION OVER 1000 AMPS
O Z_O I understand my plans shall be used as public records. 17
j SIGNS ELECTRICAL
rr',nF-
¢ Licensed Professional
Z:,W<' OWNER-BUILDER DECLARATION SPECIAL CIRCUFOMISC.
KOa V I hereby affirm that I am exempt from the Contractor's License law for the
m3LLy following reason.(Section]031.5,Business and Professions Coda:Any cayor county TEMP.METER OR POLE NET
which requires a Permit to consumer,alter,impmve.dcmoliah,or Japan any structure
Y7 prioo its Maurice.also requires the applicant(asucM1 pennitrr File a signed statement POWER DEVICES
rt
W ell<0 that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter
Q. .n 9(mmmencing with Section 7000).f Division 3ofshe Business and ProfessSWIMMING POOL ELECTRICions Cade) VALUATIOjj
or that he is exempnherefmmand the basis for the alleged exemption.Any violation of OUTLET'S-SWITCHES-Fl%TVRF3 2Z
FZ4Section 7031.5 by any applicant for a Permit subjects the applicant to a civil pen ally of J J
m more than five hundred dollars(S5 W).
cc_❑ NEW RESIDENMAL ELECHI S .FT.
��m ❑ 1,aaowncroDM1eproperry..rmycmployaswith wagesastheirs.lemmpenu4on. Q STORE 9'YPG CONS'1'RUC'I'ION
per- will do the work,and the structure is not immridedorssffered for sale(Sm.'AH4,Business
and Professions Code:The C.ntw.ea License law does not apply rat an Owner Of I '
property whn builds or impmvea thereon,and who does such work himsclforshroughhis
wnempl.yees,pmvided tharsuch imprmenantserc nor imm�dedoroffcred foraele.IL OCC,GROUP RES.UNI I's
however,the buildingor improvement is sold within one year.feampleti.n,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
I,as owner jethe Sec.7 y,am esclus s an contracting wish licensed contractors m
QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.4044,Business and Professions Case)The Contractor's PERMIT ISSUANCE
License Lawd.csnm applyto with rempossrns)wensed dsuunt to the Conaracand l
wraros,mcrs forsuch proj«r%widraconwcmrts)IimnuA pursuanuothe C.nuactm's
license Law.//J A/^/ ALTER-DRAIN&VGff-WATER(EA) FC•Ii SUMMARY
❑ 1 sm caAryT�1 WJcy,se.,.�_.B&P C f�hix/eaw� BACK FLOW PROTECT.DEVICE OUTSIDE FSI:
���11!/��LLL Ill/ ; SANITARY Y N
Ow D DRAINS-FLOOR,ROOF.AREA,COND. RECEIPT')
WORKMAN OMPENSATION DECLARATION SCHOOLTA% Y N
❑ I hereby affiJm that[have a cealficam ofconscnr to self-insure,or a certificate of FIXTURES-PER TRAP RECEIPT
Workers Compensation Insurance a acerdfied copy thereol'Spe.3800,Lab C.)whi #ch PARK FEE Y N
rs all employee a under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Pony# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK H
❑ Certified copy is heaby frmishW.
❑ Cenilicd copy is fled with the city inspection division. GREASF[NDUSTRT.WASTE INTERCEPTOR GRADING FEE r�
CERTIFICATE OF EXEMPTION FROM WO S' GREASE TRAP SOILS FEE
COMPENSATION INSURAN L•
(His section need not be completed if Ne parmit is to dollars(SIM) SEWER-SANITARY-STORM G.2001T. ENERGY PER
or less.)
leenifythatintheperformaneeafthe ork Nis pmmitiaissuW, I WATER HEATER WNF/ELECIR
no employ any Anson in any manner s come subject m PAID
Compereainilawsof California. D WATER SYSTEM(fREAT[NG Door Receipt If
O z Applicant
z NOTICE TO APPLICANT:IL after making s mrca ofE ti ,yousauld NEWRESIDENTIALPLMB. SQ.FT. TOTAL:
tr M1ecnme suhjecuolhe Worker's Compensminn m siorhe ode,you must
l—' forthwith comply with such provisions or this iuhall damcdmvokM. BUILDING HE
GQ CONSTRUCTION LENDING AGENCY SEISMIC HE
7 z I hereby affirm that hem is a construction lending agency for the performance of L: ♦ ELECTRIC FTE
U O the work for which this pmmls Is issued(Seo.3119],Civ.CJ
I<nder's Name PLUMBING FEE
Lcndm'a Address QTY. MECHANICAL PERMIT FEE
U I certify that 1 have read this application and stare that the above intentional-is MECHANICAL HE
correct.l agree nr comply with all city said county ordinances and state laws relating to PERMIT ISSUANCE
h 4s builiingcumwctlon,and hereby authodrs,repaxnrariveso(this city roamer upon Ne
above-mentioned pre yfor inspects pa les. ALTER OR ADD TO MECH. CONSTRUCTION TAX
L) (We)agrm to e,indemnif d P 3mesa Ne City of Cupertino aguinss
liehilities,judgme costa sehich may in any way accrue again..said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
amseyucnee the Jin il.
AIR HANDLING UNIT(OVER 10,000 CFM)
Si am fA,icaatlCmdoicro Dam EXHAUST HOOD(W/DUCO
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 B'T'U) Date Reaipl#
Will the applicant or future building occupant store or handle M1usardoua material HEATING UNIT(OVER IW.fNYJ BTU) TOTAL:
az defined by the Cupertino M Pal Codc.Cha imf 9.12,and the Health and Safety
Cale,Smiaa 25532(n)4 No VENTILATION FAN 1SINGLB RISID)
❑Ye% ISSUANCE DATE
Will the applicantorfulum bus g occupant use equipmentordevices whichemil BOILER-COMP(3HP OR 100,000 BTU)
�hamrdous air cumaminam as fined by the Bay Area Air Quality Mavgemem BOILER,COMP(OVER IW,"PTU) •" /1 .i y
Uixtricfl
Yet'
No NEWRFSIDENHALMECIL SOFT. ®(/T a6
I base mad the haurdous materials rerlulrememe under Chapter 6.95 of the b /s7a7/
C:dilornia Health&Safety Code,Sections 25505,25533 and 25534. I understand that
if@e building does notcurtemlyhaveamnant,thm isismy msponsibility to notify the ���Y Ur ..
ococcupant of the requirements which must be met prior to issuance of a Cenificam of V V rte(:, 'U
cupancy.
Owners aulM1oriud egcm Date f L ISSUED BY:
OFFICE