27371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO �' PERMIT NO.
APPLICATION/PERMIT PLUMBING'MECHANICAL
BUILDING DIVISION .„BUILDING PROJECT IDENTIF'ICAT'ION 27371
BUILDING ADD/R`REESSS�� G,A�. J• {/��p//1� SANITARY NO, APPLICATION SUBMITTAL DATE
UM LOT IT
��1.�-q >C
OWFI� `Hpp C N'TRACPOR'S NAME: LIC NO:
Y6 N/C CONTROLM
siecc
AR T C /ENGINEER: UC NO: AD RBS
�St -980 0 0 Soiv ".4'rAz
CONTACT: PHONE: v m Y x-#w a c1 Z Z =#` r s *.' ' z;BUILDING�PERMIT INFO
9%. P9E'Oa#RtikwRRI' 1 �#PEES
BLDG RIVCT PLUMB MFCFj
PERMIT ISSUANCE � !dTF�t. IKrIy I�a�q#�
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
py)Z Thereby ofrmthatl 3 of
fthnsedinss add Professions
Codr9(commencing with
u100 Section e and of Division 3 of the Business end Rofessione Cade,and my license is in ppNELS
ty�UZ fanfare Clas effect,
66 V License Class Lic.p UP T0200 AMPS PM��
on Date Contractor 201-1000 AMPS
ARCHITECT'S DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O R"C I understand my plans shall be used as public records. _
W SIGNS ELECTRICAL
LQ'trg :� Lie nred Pofammal
0yF OWNER-BUILDER DECLARATION SPECIAL CIRCUFUMISC.
Pti10I hereby affirm that I can exempt from the Commodes License Law for the
W 3 W m following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit m construct,altar,Improve,de.nolleh,m mpair any ahuomre
Y,, ,an ,,it,issuance,.krin0uires the applicant forsuch Permit to file second statement POWER DEVICES
pO shot he is beamed patrons[to the Provisions of the Coonselt r'a License Law(Chapter
a y 9(commencin th Section'001 Division Sof the Business and professions Code) SWIMMING POOL ELECTRIC
00 4 or thaoheldexempuherefromand the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES ,
Y Section]031.5 by any applicant rnr a permit subjects the applicnm ro e civil penalty of 1.
of re than
five
hu ndreddolhas($500). NEW RESIDENTIAL ELECTR S .FT.
Lasownerofthe property,o rayemployees with wagesastheirsolecompensation, Q STORIES TYPECONSTRUCTION
ywill othe work,and the structure isnotimeaded oroffered fertile(Sec.]044,Business
and Professions Cade:The Contractor's License Law does not apply to an owner of
property whobuildsorimp uvesihereogand whodees such workhimselforthrough his
own employees,providedthat such improvemenlsare mainended oroffered forsele.If, OCC.GROUP RES.UNITS
however,the building orimprovement is sold within one yearofcompletion,the owner- L
builder will have the burden of proving that he did not build or improve for purpose of
sola) TY. ?wd sd*PLUMBINGYERMIT, e APN
❑ I,asownerofthopropAy,amexaluslvelycontreeungwnhlicensedconua.osto Qv tAs }K�, r4yt� a j_>,vf EE6 F1 ODD ZONE
oml um the project(Sec.7014,Business and P ecadlons G>veJ The Contractor's
IJceede Law doesaotapply loan owneridEmpeny whobuildsorimprovasthereon,and PERMIT ISSOAN
whoconvacts forsuch projects with a commemr(a)licensed pursuanrmthe Commemrs pI,TER,DR &VENT- ATER PEE SUMMARY
License Law. (EA) p
❑ I am exempt under Sec. B&P C for this reason BACK W PROTECT.DEVI OUTSIDE FEES
SANITARY YN
Owner Date RECEIPT
co WORKMAN COMPENSATION DECLARATLppt DRA S-FLOOR.R RE ND. SCHOOL TAX YN
❑ Iherehy a[fimt.M1n.I have acenifiwte oPcovse uo�#Il.1mme oorn�,nifioateof ORES=PER RECEIPT#
Workers'Compensation lnsumnce orecenificd copy efcut(Sec.3800,Le C.)which PARK FEE Y N
arsallempinyee'sunderthisperrnil. GAS-EA.S INC. TL RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ comnw espy is nGAS-EA.S M-OR4 FA) PLANCHECK FEE
,a, �i
❑ Cenifiedcapyisfled with mmlah V city inspection division. GREAS N STR AM INTE CE OR GRADING FEE
CERTIFIC TEOFEXEMPTIONFROM OR G SOILS FEE
C MPENSATION INSU NCE s
(This action need not ompletedUth a t ' for eddollac($ O) SEWER 1 -STORM EA. OFT. ENERGY PEE O
or less.)
letmifynciddithepetfn eofNewr f w tdpermitisissue Isti 1 ` ATERIT ER WNENT/ELEC
not employ any person in any mamlei s me subject m the orkers' pgJp
Compensation Laws of Celifomi I Date TER SYSTEM/IREATING Date Receipt If
Q Z Applicant
z�Z 0 NOTICE TO APPLICANT:If,aft making this C ifi to of Exempting,y u should NE ESIDENTIAL PLMB. SQ,FT. TOTAL:
r0, become subject to the Workers ndatlon provi' sof the Labor Code youmadt
forthwith comply with such providio or this perm".shall be deemed my ed. BUILDING PEE
pWp Q CONSTRUCTIO ENDINGAGENCY SEISMIC FEE
rte' z Thereby affirm that there is a ennsw n lending a y for.he performance of ., FLLCTRIC FEE
O the work for which this pamtit is issued(Sec. v.CJ
ti
Lenders Name
F Lenders Address ,QTY" # 4rMECIIANWALPERMITr,f FEE,,, PLUMBING FEE
U I cert ry That 1 have read this application and spite that the above infommdon is
W mvem. I spree to comply with all city and county ordinances end spire laws relating to PERMIT ISSUANCE MECHANICAL FEE
rOn building construction,and hereby authorize representatives ofthis city to enter upon the CONSTRUCTION TAX
U above-mentioned propeny for inspection purposes. ALTFRORADDTOMECH.
(We)agree to save,indemnify and keep hsnrdess.he City of Cupertino against
Iiab1111ies,judgments,costa and expeneswhlch may in any way accrue against said City AIR HANDLING UNIT IT 010,000 CFM)
n cons epee of the granting of Ipermit.
/I �� AIR HANDLING UNIT(OVER 10,000 CFM)
i,ratmeol Appli.am/Contmmor Dao EXHAUST HOOD OMMUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE L HEATING UNIT(TO 100,000 BTU) /a Date Receipt#
Will the applicial or future building occupant store or handle hazardous material ABATING UNIT(OVER IUO,IX)0 BTU) TOTAL:
as defned by the CRpenino Municipal Code,Chapter 9.12,end.he Health and Safety
Code,Section25532(a)? Fpts
VENTILATION FAN(SINGLE RESID)
11 Yes 11 Na
Y�
Will the applicant rfumrebulidingoccupem
nseequipmenfor devices whichamh BOILER-COMP(3HP OR 100,000 BT U) I'UANCEDATE�'r,l
hazalloud air contaminantsae defined by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) F LUN �,9
District?
❑Yes 0 N NEW RESIDENTIAL MECH.-SQ FT. �r/H
1 have read the hazardous materials requirements Rader Chapter 6.95 of the 0
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must Ice met prior to issuance of a Cenlficete of
Occupancy.
Owner or authorized agent Data T ISSUED
OFFICE