27617 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIO NO APPLICATION/PERMIT - PERMIT No.
BUILDING DIVISION PLUMBING IDENNIFIC
. BUILDING PR(]JF.CT•IDF.NTIFICA'I'ION 27617
BUIIAINGADDRESS: SANITARY NO. APPLICATI]ON
SUBMITTAL DATE
KIS I17a� UNIT# LOT# 1�1. a �s
OWN+ Sw`-E: PHOy@: CONTRACTORS N�:E:� `! LIC NO:
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M/ME 3� AM ,�VIr i�V! NIC CONI RO1.N
❑TE /ENG [R: LIC NO ADDRESS �.ad.lV]al ❑
I CONTACT: PHo aY., g # FLEC7'ai.,A4RM]T : sPEEa}a `°19IIILUING PERMIT:INFO '.
_s� mr S > S '*x aarc :".,.: . -B1w ELECT PLUMB PIii—
LICENSED
-
PERMIT ISSUANCE r]/' (��yJ '
LICENSED COM RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �+
JOB DESCRIPTION
QtL'Z Iherchyaffinnthat l am licensed underprovisions ofChepter 9(commencing with
P400 Section]000)ofDivlsion 3 of the Business and Professions C de,and my license is in PANELS
id1—. fall force and ane"
t
' 200 AMPS
ar6a Datense 1.Cluss — Conrzactor 201-IIDWAMPSD.
�• ��
Z F0 y-z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O2—Q l understand my plans shall be used as public records.
rr y t W SIGNS ELECTRICAL
Licensed professional
Ly+ 6 OWNER'BUILDER DECLARATION SPECIAL CIRNIT/IMSC.
PZ'Oy0 I hereby affirm that 1 am exempt from the Canwcmra License Law for the
miliov00'3 P.m whichinguiresaermit toco31.5ct,altr,improve,
demolish,
Order:Any city structure TEMP.METER OR PoLE W$T.
o 0 which requires n permit na construct,nhep improve,demolish,or repair any structure
QC) that he its issuance,olsmttoth thevisios ficarstwit Ctupermltm filLicense
La smtement POWER DEVICES
W
QC) 9(commencing
c he isnlicensed
with Seanuat)(0)of provisions the Contractors License Cates Code)
SWIMMING POOL ELECTRIC a o 9 that he is exemlth ection]000)of leadsiaame thenot BusinessandProfessions Code) VALUATION
yY]_y arthahelsexempuherefromendthabasisfonheallegeAexcmption.An,violetionof OUTLETS-SWITCHES-FIXTURES / 4�
4 in in ]03 LS by any"Pan'an[for a permit subjects the applicant to n civil penalty of /
Q not more than five hundred dollars($500). NEW RESIDENTIAL ELECTR S .FT.
p l�I,asawneroRhepropeny,ormyemplayees withwalasnstheirsolecompersam on, Q STORIES TYPE CONSTRUCTION
y3°y will do the work,and the structure isnot itnendedorofferedforsde(Sea.]IN4,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimpmvesthereon,and whndouessuch work himselfonhmughhis OCC.GROUP RES.UNITS
own employees,providea thatsuch impmvementsamnotintendedorofferedlbrsale.If,
however,the buildingor improvement is said within one yearef completion,the owner- L,
builder will have the burden of proving that he Aid not build or impmve four purpose of or
s❑)I,asct
ownofthe property,can exclusively contracting with licensed contractors an QTJ i4 roPLUMBING PGIiMIT" }r'F, t ° EH- n FLOOD ZONE pPN
consume,the project(Sec.7GA,Business and Professions Code)The Contimman s
License Law domain apply roan ownerofproperty whobuilds mmnpmvesthereon,amd PERMITISSUANCE
who contracts forsnch projects withaccabacmr(s)licensed pureuanuomaComtmctars ALTER-DRAIN&VENT-WATER(FA
License Law. •FEE SUMMARY`
❑ I nm exempt under Sec. ,B&P C for Nix rearon BACK FLOW PROTECT.DEVICE OUTSIDE ,ES
SA ARY Y N
Owner - Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihercby affirm thatlhave ecertifcew of aoneenno self-losure,ora eertiflcam ofRHCPJPT#
FIX'I'UR[S-PER TRAP
Workem'Compensafion Insurance oracenifiedcopy thereof(Sec.3800,Lab CJwhich PARK PEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS ..P.IT;#
Policy is BUILDI ON FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCIIECK FEE ZV
4C��PPifiedimpy isherebyfumished.
/Cenified copy is filed with the city inspection division. GREASFINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need aabe completed ifthe permit is frrom hundoeddollam($1f10) SEWER-SANITARY-STORM EA.201 ENERGY
or less.)
I certify that in the per6nmance ofthe work far which Nisperunit is is med,I shall WATER HEATER W/VENT/F.LECTR
not employ any person in my manner so as to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER SYSTEMOTHATING Date ,c,ipt#
O z Applicant
z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
E~ GO) become subject to the Worker's Compensation provisions of the Labor Code,you must
a 1 forthwith comply with such provisions at his permit shall be deemed revoked. BUILDING FEE b
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that hem is a construction lending agency for the performance of
the work for which this pemtit is issued(Sec.3097,Civ.C.) TOTAL: HLECTRICFEE
pOF Lenaers Address QTYT r $MECHANICAL PERMIT i a , ,'FEE,, PLUMBING FEE
U 1 certify that I have read this application and state that the above information is a'-
>" LTa correct.l agree to comply with all city and county ordinances and state laws tainting to PERMIT ISSUANCE MECHANICAL FEE
E" building constroction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
U 7 above-mentioned properly for inspection purposes. ALTER OR ADD TO MECH.
(Wo)agree to save,indemnify and keep barrenness the City of Cupertino against pp p^�
liabilities,judgments,costs andexpemseswhich may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM) A I V
in consequence of the granting of this permh. .
AIR HANDLING UNIT(OVER 10,000 CPM)
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) e
PAID
PR
IIALARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,01K1 BTU) Data _ Recei
Will the applicant or future building crede,C a pierut 9. 2,and le the Hzadhus and aterialSafety Up tlur�1141"w
HEATING UNIT(OVER 100,000 BTU) TOTAL:
as defined by the Cupenl o pal Cada,Chapter 9.12,and the I loahh sod Safrty
Code,Section 25532(x)'
❑Yes o
VENTILATION PAN(SINGLE RF.SID) •'n+^�"-'« --_-- ---+•v,- \
Will the applicanmrfuture building occupant useeyuipmentordevices wM1ichemit
BOILER-COMP QHP OR 100,000 BTU) ISSUANCE DATE
hicalloux air contaminants itfined by the Bay Area Air.Quality Management BOILER-COME(OVER 100,000 BTU) PLANNER APPROVAL REQUIRED
District?
❑Yes lerNo NEW RESIDENTIAL MECH. SQ.Ff, PRIOR TO FINAL OCCUPANCY
1 have read the hazadons materials requirements under CWher 6.95 of the
Califomia lleyY1&Safer Code, 25 25533Z25lundarstaod that _
ifi (ng Ger rrently h to t dlry to nadtY aeco t of ,mems w or f n Certificate of
O oc
O r am ou'. Data 'TOTAL: ISSUED BY:
OFFICE