27226 APPLICANT TO FILL IN INFORMATION WITHIN RED t SE BALL POINT PEN ONLY
CITY OF CUPERTINOuunDLNG.ELRCrRI.AL THEME r NO.
BUILDING DIVISION APPLICATIONIPERM PLUMBING-MECHANICAL. /� n[�
BUILDING PROJECT IDEMI'IPICATION L G v
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMI TEAL DAH?
�-r7�q Po PQa
UNIT# LOT Z
W ERS NAME: _ pHA NE:
CONTRACTOR'S NAME:cq CO_ LIC NO:CC•J•l/D_ N/C CONTROL#
RCHITECf/13NGINL'hlU LIC NO: ADD SS: ❑
CONTACT: PHONE.:
QTY. f:LHCIRIC PERMIT PI?H BUILDING PERMIT INFO
BLDG F-E >_Mtl MP
LP
PERISSUANCE!LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby affirm that l sm licensed under provisions of Chapter 9(commencing with
�s100 Section 7000).fDivision J.fthe Bammss°nd Profusions C.dgand my license is in PANELS
eclj full force and SKI.
FZm UPT02WAMNLicenm Lia#
De Cochrf=h
201-1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
zcyz ARCHITECTS DECLARATION OVER JOSE AMPS
OZ O I understand my plans shall be used as public records.
F rn ; SIGNS ELECTRICAL
Licensed Professionala' 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
OaF 1 hereby affirm that 1 am exempt from the Contractor's License law for the
3001 following reason.(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.M=,R OR POLR INST.
,oJ which requires a permit to construct,alter,improve,demolish,or repair any structure
,n prion.its iuuance,ilsd requirestheapplicant fm such permit1.fileasigned statement POWER DEVICES
QO that he is licensed pursuant o the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
e� 9(commeming with Section 7000)of Division 3°fthe Business and Profusions Code) •--� VALUATIONvT
or that he is exempt therefrom and the basis for the alleged exemption.Any violation.( OUTLETS-SWITCHES-FI%TURFS I 3 o DOD s [l
Z Q Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
y$p t more than Ban hundred clop.D500). NBWRESIDPNTIALELECTR —SQ.FT.
W m n❑ I,asownu°fthepropeny,.rmyemployuawith wages radmirsolecompenaati.n, STORIES TYPECONNRUMON
q willdo thework,and ahestructum ianm imendedoroffiond forsale(Sec.7044,Business
and Profeta mor Code:The Comanches License Law doe nm apply to on owner of
own mry'ec.,ldsmimprovu..1 iuc.mand whodtrossuch work or
olfeonhmughhL OCC.GROUT' RES.UNITS
canempinycex,providal theaeach improve it
ream proffered for sale.IL
h.werer,the building.rimprovemem is solJ within on ear ofc Iction,the owner.
buildu will have the burden ofproving that he did no wild orimpro purpose.(
sale.).
❑ I,as owner affix property,amexclusively c ractingwiNlivemcdc°mmet t. QTY. PLUMBING PERMIT FEE 1+LOOD-LONN. APN
construct the project(Su.7044,Business fessions Code:)The Common PERMIT ISSUANCE
Licenu Lewdocs noupplyroen owner.Eprc rrywhobi ilds.ri theramuturd
wharmarnaasf.rsuchpmjecaswit ttomit musUicensedpurs° °The Coma, 's ALTER-pRA1N&VENT-WATER FA
License Lou. ( ) FEESUMMARY
❑ Lem exempt under 5<c, or this re BACK FLOW PROTECT.DEVICE. UT DI.
SANITARY YN_
caner RECEIPT#
DRAINS-FLOOR.ROOF.AREA,CONE),
WORKMA COMPENSATIOND TION A SCHOOLTAX YN_
p Ihertby affirm that lh eettnifacate Ecorse m ITinsure,o I�te. RP.CF.IPI'p
"3L�1 FIXTIIRIS-EBR TRAP
41c.semidletalpi.yee',turadert
nrkeri Compensation]oats nee.recrnit co t m (Sec.3g oh whi PARK FEIi Y N
pc.I,. GAS.EA.SYSTEM-IINC.40VILETS RECEIPT#
Policy# BUILDING DIVISION Mt
Compact GAS-EA.SYSTEM-OVER 4(IRA)) PLANCHECK FEE20 <-7
❑ nificd copy is hereby fumis
Certified copy is Bled with tbecity mioZd\Q.. GRPASFIINDUSTREL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTIWORKERS' GREASE TRAP SOILS FEF.COMPENSATION INSE
nehu redd.11an(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or less.)
I certify thin in the pert.mmnccnfahe work for wLichthia pcmait is ismcd.I shall WATER HFATER W/VENT/EE.ECrR
not employ any person in any manner so to;to become subject to the Workers' pplp
z C.mperuationlawsof Califomia, Data WATER SYSTEM/fRPATING Data euI"#
O O Applicant
NO]]CE TO APPLICANT:IL ager making this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ,FT. TOTAL: s3)
tr-I V] become subject to the Worker'aCompensation provisions of the labor Code,you must
7 forthwith wmply with such In..mon,.,,his permit shall be domed revoked. BUILDING FEE BIf
Z CONSTRUCTION LENDING AGENCY SEISMIC hEIi
T hereby offrm that is a construction lending agency for the performance of T ELECTRICMICF FT
U Q the work for which this permit is issued(Sec.3147,Civ.C.) ��
Lenders Name PLUMBfNGEE
w0 U Leaders Address QTY. MECHANICAL PERMIT FEE
1 certify that 1 have rtad this application and state that the move infmmmion is
>. UJ cnnect.lags h;i' 'with ell city and county ordinances and state laws relating to PERMIT ISSUANCE �� MECHANIC LFEE
aE;t building c.nsvuction"ce
ize rcpresemeti cs of thio city to enter upon the CONSTRU 'ION TAX
U 7 aMve-mrntinned pron putprse ALTER OR ADD TO MECH.
�^ (Wc)egrte sd keep h the cry a!Cupertino against
it. ilAn"'judgm Inch. anyw accomagainstuid City AIR HANDLINGUNIT(T010.mECFM)m rnns yue c
AIR HANDLING UNIT(OVER 10,000 CFM)
gmnu A a Cnmmm Date - EXHAUST000D(W/D /
UCT) O PAID
HAZARD SMATERIALS DISCLOSURE HEATING UNIT(TO 10(1,000 BTU) am Receipt#
Will the applicant or future building occupant store or handle hazerdous material HEATING IINIT(OVI3R 100,000 tlTU) 7
as defined by tileCupenim,Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(g?
❑Yu 11 No VENTILATION FAN(SINGLE RESIDE
Will theapp_cantorfuture buildingoccupant useequipmentordeviceaadlchemit
BOILER-COMP(3HPOR 100,000 BTU) ISSUA CE DATE
hazatdow air comamineau u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Daniel? ®�
❑Ya 13N° NEW RESIDENTIALMI?CHEr.
. SQ.
go
1 have mad the hozard°us araedats requirements under Chapter 6.95 of the Zs
California Health St Safety Code.Sections 25505,25533 and 25534.1 undersmnd that la l
if ahc huilding doe-am currently have n tenant,thea it is my responsibility to notify the
occupant of the requirements which must be met prior to iuuance of a Certificate of
Occupancy.
Owncroramhoriaulagem Data f ISSUED BY:
I'
OFFICE