27444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO H ICI .L.CTRI AL PF.RMITNO.
APPLICATION/PERMIT PLUMBING MECHANICAL. 27444
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: �/� SANITARY NO. APPLICATION SUBMITTAL DATE
/0090 PHARLAP As'I_ UNIT# LOT is
OWNERS NAME PHONE: CONTRACTOR'S NAME: LIC NO:
NAND 9qb—$W4 F_ 55 N/C
ARCHI'IECI'/PN fisHER: LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. CLECTRIC PERMIT PEP. BUILDING PERMIT[NFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz I herebyaffinmhat l mn licemudunderprovisions of Clopter9(commrncingwith
F4CO Sectio..7M)).f Division Sof the Business and Professions Code,and my license is in pprypLg
Fly U� full force and effect.
Fza License Class Lica UPT0200AMPS C.IA LNN—
Data Camractor 201.101)AMPS
�J• l
ZONZ ARCI[H ECTS DECLARATION OVER 101)AMPS SQ.IT.FLOOR AREA $/SQ. .
O z ❑ I understand my plans shall he used as public records.
.y. ; SIGNS ELECTRICAL
Licensed Pmfcssionnl
Ot I tors BUILD ER DECLARATION Co...,',ION SPECIAL CIRCUIT/MISC,
OiU I ngherebyreal n.(Se thus 1 am exempt from the Cono License Law for the
W 3 o y following reason.(Section 7031.5.Business mud Professions Code:Any city structure
TEMP.METER OR POLE INST.
t�ot; which reyuircauPermit mconsvuct.ober,improve,demolish.or repair any..tectum
�y}� prior to its issuance,also requires the applicant for such Permit to mm POWER DEVICES file a signed suue
�j K 0Om that he is licensed pursuant to the pmvisians of the Contractors License Law(Chapter
p•KeLL 9(comorencing with Section 7")ofDivision 3 ofthe Businessend Professions Code) SWIMMING POOLE IC VALUATION
W—rn or that he is exempt herefrom and the hasis for the alleged exemption.Any viol.......of
z,< Section 7031.5 by any a,fcimfor upchu itmbjecu the epplicanuo a civil peachy of omm.pyrfiHfis-FIXTURES
= not mom than Eve hundred dollar($50(1).
N. 1) ❑ I,esowneraftheprolxrty.ormyemployceswithwegnsstheirsolecompensauon. NE IDINTLALELECDt _SQ.FT. 5 RIES TYPE CONSTRUCTION
will dothework.and the strums isnot imendedoroHemcl fmsale(Sec.7044,ismusass
and Professions Code:The Contactors License Law don not apply to en owner of
propenywhobtildsorimprovesthercon,and whodons suchwork himulforthrough his MC.GROUP RES.UNITS
own employees,provided that such impmvcmenuarcratimended pf,'.emdforale.1L
however,the building or improvement is sold within crayons complaisur the owner TOTAL:
builder will have the harden of proving thin he did not build arms for purpose
sale.).
❑ 1,as owner ofthe property,am exclusively contacting with liZ'shimanoat QTY. PLUMBING PER FEE 17000 ZONE, APN
construct the project(Sec.7f ,Business and Professions Codep'ITe Contractor'. PERMIT ISSUANCE
License Low does not apply loan ownerofproperty who builds m improves thereon,en
whocomrmisfor such projects withncumracmo,i)licensed pureurnoideCotnmmors AUI HE-DRAIN&VE R(EA) PI?E SUMMARY
License Law.
❑nl em exempt under Sec. B&P C for this reason SACK PLOW PR VICE. OUTSIDE FEES
SANITARY Y N
• Owntt R RECP.IPI'a
DRAINS-FL R, F,AREA,C
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ IM1ereby nlErm thmlhaveviceniMme of consenuoself-insure,orecertificete of p1X)LRES. R RECEIPT Is
Workers'Compensution Insurance ora certified copy thereof(Ses.3800,Lab CJ which PARK FEE Y N
covers all employer's under this permit. GAS-RA.SYSTRM-1 .4 5 RECEIPT is
Policy a L t� BUILDING DIVISION FEES
Company Li17 • 1 rs S-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cahr E co'' Ipy is herebyfamished.
mieesified copy is filed with the city inspection division. GR SIWNDUSTRLWASTEINTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR PA 'TRAP SOILS FEE
COMPENSATION INSURANCE
(This sectio....cedant be completed inhe permit is for one hundred do]]=($100) SEWER-S TARY-STORM G.200 . ENERGY FEE
or less.)
I certify that in the performance of the work for which this permit is issued,l shall WATER HBATER WN CIR
not employ any Person in any manner so as to become subject to the Wmkcm' PAID
Compensation L.awsof California. Date WATER SYSTEM/IREATING Data Receipts
z Applicant
z�'7 � NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
became subject to the Workers Compensation provisions of the Labor Code,you must
Fa H forthwith comply with such provisions or this panni,shall be deemed revoked. BUILDING FEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the Performance of
this work for which Nix petit is issued(Sec.3097,Ci,C.) TOTAL: ELECTRIC FEE
(1. Lenders Name
O F Lender's Address QTY. MECHANICAL PERMIT PEE PLUMBING EBL'
U 1 certify that 1 have and this application and state that the above information is
correct.I agree to comply with all city and county mrdinanen and state laws relating to P13RMIT ISSUANCE MECHANICAL FEE
hbuilding construction,and hereby authorize representatives ofthis city to enter uponthe CONSTRULTIONTA%
U above-mentioned property,for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify and keep handless the City of Cupertino against
liebilities,judgmetns,costs andexpen¢swhich may in any way accrue against said City AIR HANDLING UNIT(TO 1.0(10CFM)
in consequence Of the granting fNis permit. �y AIR HANDLING UNIT(OVER 10,01)CFM)
Signature of Appliumi/Comacmr Date EXHAUST HOOD OVIDUCT1 PAID
HA7ARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,000 BTU) Data Raeipta
Will the applicant or future building occupant state or hadile hazardous material HEATING UNIT(OVER IW,tUp BTU) TOTAL:
as defined by the Carolina Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(e77
11VENTILATION FAN(SINGLE RESID)
❑Yes ❑No (L�( ITS
TE
Will theapplunnuorfuture buildingoccupant useequiPmemardeviceswhichemit BOILER-COMP(3HPOR 10.01)BTU) I�UW YU"
hamolous air contaminants as defined by the Bay Area Air Quality Management BOILER.COMP(OVBR It10,010BTU)
DistricR //�IQ�]]j� �s, '1 oC
❑Yn ❑No NEW RESIDENTIAL.MECH. SQ.FT. (j�jPR W I9 a95jl
1 have read the loomoh as materials requirements under Chapter 6.95 of the
1 understand that CU Y ser �urttf LINO
Culifnrnin Ileulth&Sulety CWe,Scetinne 25505.25533 and 25534.
if Nc huilding does not currently have a tenant,that it is my responsibility to notify the
mcupatnt of the requirements which must he met prior to issuance of a Certilicam of
Occupancy. \
Owner or aadmd:ed agent Date TOTAL: ISSUED BY: LAFDV
OFFICE