27801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY \
rCITV OF CUPERTINO IstAL LNG-hLELTI MU PERMCTrvO. /� 80
APPLICATION/PERMIT PLUMBING-MECHANICAL -/
BUILDING DIVISION BUILDING PRO.IN,CL'r IDENTIFICATION 8
BUILDING ADDRESS: SANITARY No APPLICATION SURMOTAL DATE
Z VVTiY WA UNIT# IATA
OW ERSNA WI gINURACTOR'SN E: r LIC NO: NIC CONI'ROLp
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/ M CHIIECI'/ENGINEER: LIC NO: D R S: ❑ D
Low ICk Au 1.� .
'ONTACT: PHONE:
// I ELECTRIC PFRMIT EEE BUILDING PERMIT INFO
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rV�. 'l�✓F� � �tS � L� :•..E:>J T b.x �.Y.LY 't.. ELECT GL>� PLUMB MFjCII
PERMIT ISSUANCE
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LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL y OR DESCRIPTION
Ihereby affirm Nal l an licensed under,rovisions of Chapter9(commencing with
¢02 Scnion 7")of Division 3 of the Business and Professions Cade,tial my license is in PANELS g `-a[-j• fulllbmeend Bled. V�n
Fe. Contmdor
Lu�nse Class D T o `
y.,6pAMpg
h. ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.PI'.
0 Q W I understand my plans shall be us p
used ublic records. ,4e •]0c6�KO-3
Fut I=W SIGNS ELECTRICAL L "
CJ Licensed Profusionul
Kya'Q OWNER-exempt omECLARATION SPECIAL CIRCUIT/MISC. p
OyF Ihereby uflitm that 1 nm exempt lion the Contractor's License lues for the
W34w following reason.(Section 703 I.S.Business end Profesainns Calc:Any city or count, TEMP.METER O0.POLE INST.
which requires a Permit to com uct,alter,improve,demolish,br repair any structure
ern>� pd., its issuance,also requiredeapplicantfar such pemdt m If...ignedstatement POWER DEVICES �y
q�4 p O thm he is Iicen.dI pursuant to the provisions of the Contractor s License Law(Chapter T Z-!
a 9(commencin with Section 7000 of Division 3 of the Business and Professions Code SWIMMING POOL ELECTRIC
o� (commencing ) ) VALUATION
�m or that he is exempt merefromund the basis fndbeallegcd exemption,Any violation f OUTLETS-SWITCHES-FUCNRES U
�Za Semion]03 LS by wyapplicumforapermil subjects the applicennoacivil penehy of
Sz no am than Evchundreddollars($500). NEW RESIDENTIAL ELECTR _SQ.FT.
W m ❑ 1,usownend,heproperry,onnyampinyaeswi,h wugaas theirsolecompensation, STORIES TYPECONSTRUCHON
a will do the work,and the structure is not inendedmorfered forsale(See J04I,Business
and Professions Code:The Contactors license law docs not apply to an owner of )O
properywhobuilds.rimproves,hereon,etdwhodoessuchworkhimselforNroughhis OCC.GROUP RHS.UNITS
ownentployces,pnwided that such improvaIf,
however,the building or improvement is sold within one year of er mpletion,the nwner- T m
builder will have the bund,.of proving the he did not build or improve for purpose of
❑
mile.).
a
¢ PLUMBING PERMIT, EBn
Las ownernrhcpm property,stn exclusively conacng with licensed exammemrt f aIq,00D ZONC APN
construct the project(Sec.7044,Business and Pro entions Code:)The Contractor's
License Lawdoes maimlym an ownerofproperty whobuildsorimpmvesdoeon,and PERMIT ISSUANCE
whoconmcts fnsuch Pmjcets with acanmmorfs)li¢nmd purmand Off,Cmaracmrs
ALTER-DRAIN&VENT-WATE
uanxe Law. FEr'SUMMARY
❑ I run exempt under Sec. ,B&P C 1'or this reason BACK MOW PROTECT.DEVICE 's UTSIDI: ES
ANGARY Y N
Owner Dee DRAINS-ROOR,R ,ARLA.COND. RECGII'T#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
I hereby effimnM1e,Ihuveacedificatc nfdmsenun self-insure,or a ruffcee of W)CI'URES-PER RECEMP.
Worken'Compensmion lnsumnceorace.ifedcWythereof(Sec.311130,tab C.)which PARK FE[: Y N
use_
nail employe's d th GAS-PA.SYSTEM-II 40UTLE1'S RECEIPT#
If Y. BUILDING DIVISION FEES
Company a' ��1'�(.f�, GAS-EA.SYSTErvlsfl R4 ,A) �a� PLANCIiIiCK FEE
❑ Certified copy is M1erery tiro. al. t+
❑ Certified copy is Filed with Ne city impaction division. GREASEANDUSTRI. S NTERC R GRADING FEE
1 4
CF:RTIFlCOMPENSATIONEXEMPTION FROM AN WORKP.RS' GREASETRAP SOBS FEC QO
COMPENSATION INSURANCE
(This section reed net he completed if the pemdt is for one hundred donnas($100) SEWER-SANITARY-STORM PA. ENERGY PEE '
.r less.)
(certify that inthe pin performance so a,for becamethis ubjectta theta kers WATER 111?nTER WNPNT/ELELTR D,?JaC
no,employ unla person li any manntt so us to become subject m the Worked PAI
z Compensation laws of Calirorniv. Date WATER SYS'I'EM/IR[iATING pure pp
Applicant
z O NOTICETO APPLICANT:If.after making this Certificate of Exemption,you should NEWRESIDENTIALPI.MB. SQ.FT. T AL:
r-1 p) became subjecuo the Workers Compensation provisions of the labor Code,you mus, a
a forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING HE
OW., Q CONSTRUCTION LlIDING AGENCY ST:ISMICFEE 6.68
Uz I bereby affirm that there is. mann ni n lending agency far the performance of
O the work far which l his Perri l is issued(Sec.3097,Civ.C.) A : Luk-> ELECTRIC FEUr
Lenders Name t PLUMBING
F Lender.Address QI Y; .i_ss' MECHANICAL-PERK7IT.• r - FIiE.k
U 1 certify mm I have reed,his applice,ion end sum deg, above informatio K
4W correct, L agree m comply with all city and county ordinances and state laws rending to PERMIT ISSUANCE MECHA C P. 1
H0, building consouction,and hereby auehnriu represenutives.fthis city to enerupon the CONSTRU ON TA
U z above-memtbned pmperty for inspection puryH.
oses. ALTER OR ADD TO MEC
(We)agree to save.indemnify and keep M1emless the City of Cupertino against
liabildies,judgmen,s,costsvnd expenses which may in any way accrue ugeinslsaid City AIR HANDLING UNII'(TO 10,000 CFM)
in eonseomatsc ognnting spemmit. AIR HANDLING UNIT(OVER pf"CFM)
J-9=sib
Signature of APPlicum/Cnnwnnr Date EXHAUST r100D(Wp)UCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1110,000 BTU) Ua,e Receipt N
Will theapplicantor fwum mildingoecepan,sort m lendlehamrdous mdedal HEATING UNIT(OVER 100,01(d)WI U) )
as defined by the Caliendo.Municipal Code,Chapter 9,12,end do,Health and Safety
Cade,Section 25.53(a)
Yee 207 ❑No VENTILATION FAN(SINGLE RESID) y' a
Will the applicwtarfuture building occupant metuluipmenumdevices whichento BOILER-COMP(31111 OR 100,0110 BTU) ISSUANIAIPDATE
arard.u.air cnnmminants m defined by the Bay Area Air Quality Management V(j ��
: IsMcf1 1301LER-COMP(OVER 100,(00 8'CU) (,
❑Va ❑No NEW RESIDENTIAL MECH. SQ.FT. -
1 have mad the lorardom materialsrequirements under Chapter 6.95 of the
Califamia Health&Solely Code,Sections 25.105,25533 not xa,[25534.1 understand that W U
I
f the building does curenm ly have a tenant,that it is my responsibility notify the
occupant of the requirements which mus,be met prior to issuance of a Certificate of
o,cupancy.
Owner nr uwhonmdagent Date TA I ISSUED BY: