27337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE.BALL POINT PEN ONLY
CITY OF CUPERTINOTGA- PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL27337
BUILDING DIVISION -BUILDING PROJECT IDF:NTIEICATION"
BUILDING ADDRESS: SANITARY NO. APPLICATION
SUBMITTAL DATE
� „��°�3 -�IAJ �� UNIT# LOT#
OWNERS NAME G PHO F CONTRACTOR'SNAMF LIC NO: NIC CONTROL# V{
l ( �Z L 3 I
RCHITECT/ENGINEER: LIC NO: AD E Si ❑
'1 CT: PHONE: 4yi b 3 2 P ;Si'k4'�: -
QTY' BLECTRICPCRMIT .'..FEE °BUILDING PERMIT INFO
'A ( 'F "T'N }BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE 0 ,
❑ El ❑
LICENSED CONTRACTOR'S DELI RATION APPLIANCES-RESIDENTIAL lOB DESCRIPTION
pa I hereby affirm than l amlicensed underprovisionsofChapter9(commencing with
t� Section]000)of Division 3 of the Business and Professions Code,and my license is in PANELS
9,Cj
yNc�'ZW Pollnse,and effect ! UP TO 200 AMPS CAWiep- -i-CK, ��..r �]
6F z License Class �.� Lic.N
rnQ y Daleay(/PL�Q Contractor 201-1000 AMPS
zOy7a ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.per.
O z-'q I understand my plans shall be used as public records.
Licensed Protest ionnl SIGNS ELECTRICAL
OWNER-BUILDERinaptfrom
Cramp ON SPECIAL CIRCUIT/MISC.
Wpp,,4 a to I hereby affirm(Se arm I am exempt from the Contractors License Law for the
3 LL m following reason.(Section 7031.5,Busimss and Professions Code:Any ,city 0r county TEMP.METER OR POLE INST.
llo,; which requires a permit to consumer,idler,improve,demwctre
olish,oromairiny su
`°1+ Prior mus issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES (�
H<0 that be is licensed pnrsmnar m etre Provisions of the Contractors License Law(Chapuv
dyo 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC - /j- VALUAT
iW_rn ornhat he is exempt herefmm and the basis for the alleged exemption.Any violation of r
4 Section V03L5b a licunt fora reub'ecps thea licanr toecivil OUTLETS-SWITCHES-FIXTURES (/ C
Y aiiy pP Permi 1 PP penalty of /`
Q i mare man five hmna"it dollars Pl500). �L
I,asnwncrnfthe t Lamp y g pensation, NEW RESIDENTALELECTR
p ❑ proper y,orm Ito ees with con esastheirsolecom STORIES P 6, ONSTRUCTION
a 3-2 w will do rhe work,and th,svuctureisnot intended or offered for sale(See.]044,Business /(/O
and Professions Code:The Contractors License Law does not apply to an owner of
popery whobuildsorimpreves there a,and who Or such work himselforthrough his
o empleyees,Provided thetsuch imp rovemenrs arennrinteadedorofferAforsale.If, OCG GROUP RES.UNITS
F wever,the building or improvement is sold within oneyearefcnmpletion,the owner-
builder will have the burden of proTOTAL
than he did not build or improve for purpose of ,
side). QTY 'I 8#PLUMBING PERMIT„° I -' FE FLOOD ZONE, APN
❑ Ins owner ofphepropetty,amexdusivelycomracnng with licensed comtractorsm m4, fg;.ACe, -lit 4 y.
constrict,the pnovet(Seo.7044,Business and Professions Code:)The Conuacmrs
License Law does not apply loanowneroferopery whobuildsorlmproves thereogand PERMITISSUANCE
who contracts forsuch projects with aconrraenor(s)licensed Panamint.the Convector's
License Law. ALTER (EA)) t:, , -FEE SUMMARY
❑ 1 am exempt under Sec. B&P C for chis reason BACK ROW PROTECT.DEVICE TSIDF.FEES
SANITARY YN
Owner DateRECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND, CH001,TAX Y N
❑ I herebyaffirm that l have acertificateofconsenun self-insure,ora certificate of FIXTURES-PER TRAP RF.CI311'I'#
Workers'Compensation lmsumncenraoerified copy therenf(Sec.3800,Lab C.)which PARK PEE YN_
rs all em Imyce's under this octopi GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy# SION FEES
Compnny�.; Cfi GAS
end
SYSTEM-OVER 4(EA) PLANCHECKFFB
❑ Certified copy is hue y umwhed.
❑ Certified copy is tiled wish the city inspection division. GREASEBNDUSTRI.WASTE INTERCEPTOR
GRADIN a
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASETRAP - SOILS FEE
COMPENSATION INSURANCE
(this section need not be completed ifthe permit is fiction,hundred dollars(SI00) SEWER-SANITARY-STORM EA.20017T. ENERGY EUr UUNtHI IIVU
Ess'.)
(certify that in the perforrnance of the.,it for which this permit isissued,l shall WATER HEATER W/VENT/F.LECTR
not employ any Person in any manner so as m become subject no he WorkersPAID
Compensation Laws0f Califorda. Date WATER SYSTEM/TREATING Date Receipt#
Q Z Applicant
y NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLUL SQ.FT, TOTAL:
f~ fA become subject to the Workers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or his permit shall be deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z
I hereby affirm that Nero is a construction[ending agency for the perPmmamc,of
U C) the..,it for which this permit is issued(Sec.3097Civ C. TOTAL ELECTRIC PEE
ILi Lenders Normo 1 I =T2#g@e Aj 'y3r} Fc Xr £1 -
O F Lenders Address QTY. *i i "MCCHANICALvPERMITx'v h x t - .F? 1,
PLUMBING ItiG
U I cenify that I have read this application and spate that she above information is k w
correct I agree to comply will,all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building constriction,nndhereby authorize representatives ofrhie city mentor upon the
U idose-menticanedproneed.purposes. ALTERORADDTOMECII. CONSTRUCTION TAX
agree to save,indemnify and keep harmless the City of Cupertino against
li es,J Jgments,costs and expenses whichmayinanywayacerueagidns aid C' AIR HANDLING UNIT(TO 10,000 CFM)
wase, ace of she gnarling of th' perm. N
AIR HANDLING UNIT(OV ER 10,000 CFM)
S' re of Applicant/Contna, r - Date f EXHAUST HOOD(W/DUCH
PAID
HAZARDOUS MATERIALS DISCLOSURE t T HEATING UNIT(10 100.000 BTU) F Date ReceipnN
Will the applicant or forum building occupant score or handle Instructions material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,"BTU) TOTAL:
Code,geed 25532(a)?
El Yes ❑No
VENTILATION FAN(SINGLE REBID)
❑
Will air contaminants
sbuilding by thentay-Ama Air Quality
BOILER-COMP(THP OR 100,000 BTU) ISSUANCE DATE
hazardous air coomminants ns defined by the BeY Area Air Qoniity Mwegement
Distils? BOILER-COMP(OVER 100,ODU BTU)
❑Yes ❑No NEW RESIDENTIAL MECI1. SQ.FT.
I have read the hazardous materials requirements under Chapter 6.95 of the
California I le dih&Safety Code,Sections 2550.5,25533 and 25534. I understand that
huilding does not currently have a tenant,that It is my responsibility to notify the
ceu not of the requirements which mus be met prior m Issuance mf a Cerifioene of J
t
r or amp ooze e n brafe TDTAL: ISSUED BY:
OFFICE