27063 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBon..D1 in-ri.T,'r1i PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL O
BUILDING DIVISION BUILDING PROJECT IBRNA IF'ICATION
63
BUILDING ADDRESS: SANITARY NO. APPLICA'HONSUBMTALDATE
�V / UNIT is LOT#
OW HRSNAME: PHONE: CONTRACTORS NAM L: LIC NO:
µ e I �sr t / N/C CONTR01.X
%RCHITF.CT/ENGINEER: LIC NO: AD RESS: 1. �l� ❑
2-
CONTACP: PHONE: tk - ' -
/`1—�—y �(�/�� 1, /l I�y�(J QTaY- fit
I'.ELECTRIC PERMIT PEE - '_BUILDING PERMIT'INFO
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PERMITI59UANCH BLDG ELECT PLUMB MGCkI
❑ ❑
LICENSED CONTRACTOR'S DECLARATION APT ANCES-RESIDENT L IOD DESCRI ION
0Wz I hereby efforttba l um licensed underprovisions of CTopter9(commencing with
Fv00 Section 7")of Division 3 ofthe Business and Prnresaions Cade,nudity lianseis in E S 1T�i,F 1 ,
y�4UUl full farce and effect. 2 M
Z W License Class Lic.q
mQy Date Contractor
ARCHITECTS DECLARATION E I AMP SQ.FT.BOOR AREA fISQ.FI'.
z8C RZ
O z_Q I understand my plans shall h used as public records.
_SANS ELECTRICAL
QLicensed Professional
-
259 OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
° O e.F 1 hereby affirm that 1 um exempt from the Contractor's License Lew for the
m 3 6 q¢r following reason.(Section 7031.5,Business and Professions Curb:Any city m mum, TEMP.METER OR POLE INST.
I"'E,Doc J which requires a permit to construct,alter,improve,demolish,or repair any structure
7;7 prior to its issuanm,also requires theapplicant f...ch permit.file.signedsme ..I POWER DEVICES
as O that he is licensed pursuant to the provisions ofthe Continuities License law(CTnpter
a p�' 9fammencing with Section 7")of Division 3 ofthe Business and Pmlessions Cade) SWIMMING POOL ELECTRICqrr__�� VALUATION
.,y or that he is exempnherefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES FIXTURE
T_ZQ Section 7031.5 by any applicant for a permit subjects the applicant.a civil penalty of
G not mora than five hundred dollars($500).
m ❑ I,u mvitero0hepropeny,ormyemployecs with wages asthelrsolecompensatinn, NEW RESIDP.N'TIALELECTR SQ.F / STORIES IYPF.CONS'1'RUCI'ION
y3— will dot he work,and Oteawc.relaurel intended moRered for sale(See 0144,Business
and Professions Ccx1c: the Contractor's License Law does not apply to an owner of
property who builds or improves thereon,rand who docs such work himself or through his
awn employeea.providcd that such impravemenss emnotimwdedoraffercd(orsnle.
If. OCC.GROUT' RES.UNITS
however,the buildingor improvement is sold within oneyear ofcompledon,the owner- OF T
builder will have the burden of proving that he did no,build or improve for purpose of
salt.). e
❑
[,as owneroftbe pmproy,am exclusively contracting with licensed ommuden to QT71,'G, PLUMBINGPERMIT > ,,_k FEE FLOOD ZONE APN
orramet the project(Sec.7044,Business and Profosdons Code)The Contractor's
License Law does not apply tommmerofp.ptny whoboldsofimproves thereon,and PERMIT ISSUANCE
who codamets for such projects with aconmac.r(s)licensed pursuant.the Committers ALTER IFA
License Law. ) HTE SUMMARY
❑ I am exempt under Sec. ,B&P C for this imson BACK FLOW PROTECT.DEVICE. IDH FE
SANITARY YN
Owner Dae RECEIPT#
DRAINSFLOOR,ROOF,AREA,CONU.
WORKMAN COMPENSATION ofoo DF.CLARA'UON SCHOOL TAX Y_N
❑ Ihereby Curopermmthatlhaveae.,.cateof consenuoof(Sosure,er Lab C.)c which
RECEIPI'tl
WorkcnCompcnsntion lnsumnworacminedwpythcmof(Soo.3800.Lab CJahich FIXTUR[3,PER TRAP PARK FEE YN
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT X
Policy X BUILDING DIVISION FEES
Company GAS-G.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Cenifed copy is hereby famished.
❑ Cenifedcopy is sled with theciry inspection Jivisinn. GREASMNDUSTRL WASTE INTERCEPT OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS PEE
COMPENSATION INSURANCE
This swrionncednat hecompleted ifthe permit is tonne hundred dollars($100) SEWER SANITARY-STORM EA.209FT. ENERGY FEE
or Ins,.)
I conify that in the Perfnnomea.fthe work for which this permit is issued,)shall WATER HEjvrIER WNENT/F.LECI'R
nm employ y n any mamer so a r s Peet.the Workers' PAID
Compensationn r fCelif t WATER SYSTEM/IREATING Dae RweiptX
Z Applicant _� u w
O0 NOTICETOAPPLICANr:IL.f,r, thgt6itC- van.. .annIniogyoushoild NEWRPSIDTBTUALPLMB. SQ.FT.
1-" h become subject to the Workers Compensation TOTAL:
pe Provisions The Labor Co,kol. must
forthwith comply with such provision or This permit shell be domed invoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending Agency far the performance of
U O the work for which this istnnit is issued(Sec.3097,Civ.C.) IELECTRIC FEE I
Ismer's Name PLUMBING FEE
O U Lender' ,Address QTY. -MECHANICALPERMIT FEH
1 certify Not I have read this applicnion and state thin The above information is
comet.l agree to comply with all city and county ordinances and mute Iowa relating toPERMIT ISSUANCE MECHANICAL IEE
F" U) building construction,and hereby authorize representatives ofthis city to enter uponthe CONSIRUCf10N TAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap Thornless the City of Cupertino against
ithilitics,judgmenn,costaundexptnseswhich may in any way accrue agtinstsaid City AIR HANDLING UNIT(TO I0,09)CFM)
In came...nice or the gmmimg or this in mtit.
- AIR HANDLING UNIT(OVER 10,11011 CFM)
Signature of APplicem/Contnour Date EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Data R
Will the applicant or future building occupant store or handle hasurdous material
..defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,009 BTU) A
Code,Section 25532(.)7
11 Yes El No VENTILATIONVENTILATIONPAN(SINGLE RES][))
�iSS�UANCE DATE
Willthea Ileum nr fwureM1uildin uamusee tordeviceswhich omit BOILER-COMP(3HPOR 1l10,0001i'IU) vY
poen gacc p yea Air
harirdous air contaminants us Defined by the Buy Arca Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU)
/
❑Yes GYNO NEW RESIDENTIAL MECH.—SQ. SEP 2 FT. 1 �I(In rr
I have rex the harurdo is materials requirements under Chapter 6.95 of the (! 1JJ/�
California He &Sm'ety Cade,Swoons 25505,2553)and 25574. I undemunJ that C!1 y L/r VV
irthehuildi atanot currently haven Ten,rate it ismyresponsibility.natifythe /vtN 11111 1
x:cupum a recuiremans which must be mm prim.Manure of.C Ain m of V
Oceupan
Owner or authorized agent I Da `i TOTAL: ISSUED BY, /
OFFIC